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Foltz MH, Seidenstein AH, Almeida C, Kim A, Jain A, Middendorf JM. A quantitative review of finite element-based biomechanics of lumbar decompression surgery. Biomech Model Mechanobiol 2025:10.1007/s10237-025-01936-9. [PMID: 40392425 DOI: 10.1007/s10237-025-01936-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2024] [Accepted: 02/21/2025] [Indexed: 05/22/2025]
Abstract
Lumbar decompression surgeries are commonly performed in the USA to treat pain from spinal stenosis, often with little to no biomechanical evidence to evaluate the risks and benefits of a given surgery. Finite element models of lumbar spinal decompression surgeries attempt to elucidate the biomechanical benefits and risks of these procedures. Each published finite element model uses a unique subset of lumbar decompression surgeries, a unique human lumbar spine, and unique model inputs. Thus, drawing conclusions about biomechanical changes and biomechanical complications due to surgical variations is difficult. This quantitative review performed an analysis on the stresses, forces, and range of motion reported in lumbar spine finite element models that focus on spinal decompression surgeries. To accomplish this analysis, data from finite elements models of lumbar decompression surgeries published between 2000 and December 2023 were normalized to the intact spine and compared. This analysis indicated that increased bony resection and increased ligament resection are associated with increased pathologic range of motion compared to limited resection techniques. Further, a few individual studies show an increase in important outcomes such IVD stresses, pars interarticularis stresses, and facet joint forces due to decompression surgery, but the small number of published models with these results limits the generalizability of these findings to the general population. Future FE models should report these spinal stresses and incorporate patient-specific anatomical features such as IVD health, facet geometry, stenosis patient vertebrae, and vertebral porosity into the model.
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Affiliation(s)
- Mary H Foltz
- Department of Mechanical Engineering, Johns Hopkins University, 102 Latrobe Hall, 3400 N Charles St, Baltimore, MD, 21218, USA
| | | | - Craig Almeida
- Department of Mechanical Engineering, Johns Hopkins University, 102 Latrobe Hall, 3400 N Charles St, Baltimore, MD, 21218, USA
| | - Andrew Kim
- Department of Orthopaedic Surgery, Johns Hopkins Medical Institute, Baltimore, MD, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins Medical Institute, Baltimore, MD, USA
| | - Jill M Middendorf
- Department of Mechanical Engineering, Johns Hopkins University, 102 Latrobe Hall, 3400 N Charles St, Baltimore, MD, 21218, USA.
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Jacob A, Loibl M, Haschtmann D, Fekete TF, Varga P, Ion N, Bocea B, Wirtz CR, Richards G, Gueorguiev B, Zderic I, Heumann M. Biomechanical effects of the cephalad extent of laminotomy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2025; 34:1954-1962. [PMID: 40152993 DOI: 10.1007/s00586-025-08749-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 11/25/2024] [Accepted: 02/14/2025] [Indexed: 03/30/2025]
Abstract
PURPOSE The superior aspect of the unilateral laminotomy for bilateral decompression (ULb) typically corresponds with the superior ligamentum flavum attachment. Unlike lateral expansion, cranial expansion is considered a viable option to ensure sufficient decompression. The aim of this study was to investigate how cranial expansion affects the biomechanical stability in the lumbar spine. METHODS Range of motion of eight fresh-frozen human cadaveric L1-L5 specimens was assessed in flexion-extension, lateral bending (LB), and axial rotation (AR). The workflow comprised testing in the intact state and after L3-4 ULb with sequential increase of the cephalad extent over 4 steps: (1)25% of the lamina height = insertion of Ligamentum Flavum, (2)50%, (3)75%, and (4)100%. Throughout all steps, constant mediolateral and caudal dimensions were maintained. RESULTS Even though within the tested sequences of the workflow an overall significant change was eminent for extension (p = 0.002), right LB (p = 0.030), and left AR (p = 0.009), no significant differences was detected when comparing their five different states pairwise. At L2-3, no overall significant changes were detected for all six motion directions (p ≥ 0.107). CONCLUSION ULb induced minor instabilities to the operated segment and no instability to the cranial adjacent segment. However, the absolute increase remained small under the tested conditions, suggesting that unilateral laminotomy is a safe technique at all cranial extents. With a bone-sparing laminotomy preferred, extending cranially appears to be a viable option to achieve sufficient decompression.
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Affiliation(s)
- Alina Jacob
- AO Research Institute Davos, Davos, Switzerland.
- Schulthess Clinic, Department of Spine Surgery, Zurich, Switzerland.
- Department of Neurosurgery, University of Ulm, Ulm, Germany.
| | - Markus Loibl
- Schulthess Clinic, Department of Spine Surgery, Zurich, Switzerland
| | | | - Tamás F Fekete
- Schulthess Clinic, Department of Spine Surgery, Zurich, Switzerland
| | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland
| | - Nicolas Ion
- Faculty of Medicine Sibiu, Lucian Blaga University, Sibiu, Romania
| | - Bogdan Bocea
- Faculty of Medicine Sibiu, Lucian Blaga University, Sibiu, Romania
| | | | | | | | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
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Dhar UK, Menzer EL, Lin M, O’Connor T, Ghimire N, Dakwar E, Papanastassiou ID, Aghayev K, Tsai CT, Vrionis FD. Open laminectomy vs. minimally invasive laminectomy for lumbar spinal stenosis: a review. Front Surg 2024; 11:1357897. [PMID: 39575449 PMCID: PMC11578987 DOI: 10.3389/fsurg.2024.1357897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 10/07/2024] [Indexed: 11/24/2024] Open
Abstract
Objectives Lumbar spinal stenosis (LSS) refers to a narrowing of the space within the spinal canal, which can occur at any level but is most common in the lumbar spine. Open laminectomy and minimally invasive laminectomy (MIL) procedures are the most common surgical gold standard techniques for treating LSS. This study aims to review clinical and biomechanical literature to draw comparisons between open laminectomy and various MIL techniques. The MIL variation comprises microendoscopic decompression laminotomy, unilateral partial hemilaminectomy, and microendoscopic laminectomy. Methods A review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We reviewed 25 clinical, 6 finite element, and 3 cadaveric studies associated with treating LSS. We reviewed literature that discusses factors such as operation time, length of hospital stay, postoperative complications, reoperation rate, effect on elderly patients, patients' satisfaction, and adjacent segment disease degeneration for the clinical studies, whereas the range of motion (ROM), von Mises stresses, and stability was compared in biomechanical studies. Results MIL involves less bone and ligament removal, resulting in shorter hospital stays and lower reoperation and complication rates than open laminectomy. It improves the quality of health-related living standards and reduces postoperative pain. Biomechanical studies suggest that laminectomy and facetectomy increase annulus stress and ROM, leading to segmental instability. Conclusion Although theoretically, MIL means less tissue injury, pain, and faster recovery in the short term, the long-term results depend on the adequacy of the decompression procedure and tend to be independent of MIL or open laminectomy.
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Affiliation(s)
- Utpal K. Dhar
- Department of Ocean and Mechanical Engineering, Florida Atlantic University, Boca Raton, FL, United States
| | - Emma Lilly Menzer
- Department of Ocean and Mechanical Engineering, Florida Atlantic University, Boca Raton, FL, United States
| | - Maohua Lin
- Department of Ocean and Mechanical Engineering, Florida Atlantic University, Boca Raton, FL, United States
| | - Timothy O’Connor
- Department of Neurosurgery, Marcus Neuroscience Institute, Boca Raton Regional Hospital, Boca Raton, FL, United States
| | - Nischal Ghimire
- Department of Orthopedic, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Elias Dakwar
- Department of Neurosurgery, Marcus Neuroscience Institute, Boca Raton Regional Hospital, Boca Raton, FL, United States
| | | | - Kamran Aghayev
- Department of Neurosurgery, Biruni University, Istanbul, Turkey
| | - Chi-Tay Tsai
- Department of Ocean and Mechanical Engineering, Florida Atlantic University, Boca Raton, FL, United States
| | - Frank D. Vrionis
- Department of Neurosurgery, Marcus Neuroscience Institute, Boca Raton Regional Hospital, Boca Raton, FL, United States
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Montanari S, Serchi E, Conti A, Barbanti Bròdano G, Stagni R, Cristofolini L. Effect of two-level decompressive procedures on the biomechanics of the lumbo-sacral spine: an ex vivo study. Front Bioeng Biotechnol 2024; 12:1400508. [PMID: 39045539 PMCID: PMC11263119 DOI: 10.3389/fbioe.2024.1400508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/17/2024] [Indexed: 07/25/2024] Open
Abstract
Hemilaminectomy and laminectomy are decompressive procedures commonly used in case of lumbar spinal stenosis, which involve the removal of the posterior elements of the spine. These procedures may compromise the stability of the spine segment and create critical strains in the intervertebral discs. Thus, this study aimed to investigate if decompressive procedures could alter the biomechanics of the lumbar spine. The focus was on the changes in the range of motion and strain distribution of the discs after two-level hemilaminectomy and laminectomy. Twelve L2-S1 cadaver specimens were prepared and mechanically tested in flexion, extension and both left and right lateral bending, in the intact condition, after a two-level hemilaminectomy on L4 and L5 vertebrae, and a full laminectomy. The range of motion (ROM) of the entire segment was assessed in all the conditions and loading configurations. In addition, Digital Image Correlation was used to measure the strain distribution on the surface of each specimen during the mechanical tests, focusing on the disc between the two decompressed vertebrae and in the two adjacent discs. Hemilaminectomy did not significantly affect the ROM, nor the strain on the discs. Laminectomy significantly increased the ROM in flexion, compared to the intact state. Laminectomy significantly increased the tensile strains on both L3-L4 and L4-L5 disc (p = 0.028 and p = 0.014) in ipsilateral bending, and the compressive strains on L4-L5 intervertebral disc, in both ipsilateral and contralateral bending (p = 0.014 and p = 0.0066), with respect to the intact condition. In conclusion, this study found out that hemilaminectomy did not significantly impact the biomechanics of the lumbar spine. Conversely, after the full laminectomy, flexion significantly increased the range of motion and lateral bending was the most critical configuration for largest principal strain.
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Affiliation(s)
- Sara Montanari
- Department of Industrial Engineering, Alma Mater Studiorum—Università di Bologna, Bologna, Italy
| | - Elena Serchi
- Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Alfredo Conti
- Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum—Università di Bologna, Bologna, Italy
| | | | - Rita Stagni
- Department of Electrical, Electronic and Information Engineering “Guglielmo Marconi”, Alma Mater Studiorum—Università di Bologna, Bologna, Italy
| | - Luca Cristofolini
- Department of Industrial Engineering, Alma Mater Studiorum—Università di Bologna, Bologna, Italy
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Ding Y, Zhang H, Jiang Q, Li T, Liu J, Lu Z, Yang G, Cui H, Lou F, Dong Z, Shuai M, Ding Y. Finite element analysis of endoscopic cross-overtop decompression for single-segment lumbar spinal stenosis based on real clinical cases. Front Bioeng Biotechnol 2024; 12:1393005. [PMID: 38903190 PMCID: PMC11186988 DOI: 10.3389/fbioe.2024.1393005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/21/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction: For severe degenerative lumbar spinal stenosis (DLSS), the conventional percutaneous endoscopic translaminar decompression (PEID) has some limitations. The modified PEID, Cross-Overtop decompression, ensures sufficient decompression without excessive damage to the facet joints and posterior complex integrity. Objectives: To evaluate the biomechanical properties of Cross-Overtop and provide practical case validation for final decision-making in severe DLSS treatment. Methods: A finite element (FE) model of L4-L5 (M0) was established, and the validity was verified against prior studies. Endo-ULBD (M1), Endo-LOVE (M2), and Cross-Overtop (M3) models were derived from M0 using the experimental protocol. L4-L5 segments in each model were evaluated for the range of motion (ROM) and disc Von Mises stress extremum. The real clinical Cross-Overtop model was constructed based on clinical CT images, disregarding paraspinal muscle influence. Subsequent validation using actual FE analysis results enhances the credibility of the preceding virtual FE analysis. Results: Compared with M0, ROM in surgical models were less than 10°, and the growth rate of ROM ranged from 0.10% to 11.56%, while those of disc stress ranged from 0% to 15.75%. Compared with preoperative, the growth rate of ROM and disc stress were 2.66%-11.38% and 1.38%-9.51%, respectively. The ROM values in both virtual and actual models were less than 10°, verifying the affected segment stability after Cross-Overtop decompression. Conclusion: Cross-Overtop, designed for fully expanding the central canal and contralateral recess, maximizing the integrity of the facet joints and posterior complex, does no significant effect on the affected segmental biomechanics and can be recommended as an effective endoscopic treatment for severe DLSS.
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Affiliation(s)
- Yiwei Ding
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Hanshuo Zhang
- Orthopedics, TCM Senior Department, The Sixth Medical Center of PLA General Hospital, Beijing, China
- Navy Clinical College, Anhui Medical University, Hefei, Anhui, China
| | - Qiang Jiang
- Orthopedics, TCM Senior Department, The Sixth Medical Center of PLA General Hospital, Beijing, China
- Chinese PLA Medical School, Beijing, China
| | - Tusheng Li
- Orthopedics, TCM Senior Department, The Sixth Medical Center of PLA General Hospital, Beijing, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Jiang Liu
- Orthopedics, TCM Senior Department, The Sixth Medical Center of PLA General Hospital, Beijing, China
- Navy Clinical College, Anhui Medical University, Hefei, Anhui, China
| | - Zhengcao Lu
- Orthopedics, TCM Senior Department, The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Guangnan Yang
- Orthopedics, TCM Senior Department, The Sixth Medical Center of PLA General Hospital, Beijing, China
- Department of Orthopedics, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Hongpeng Cui
- Orthopedics, TCM Senior Department, The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Fengtong Lou
- Orthopedics, TCM Senior Department, The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Zhifeng Dong
- Mechanical and Electronic Engineering Department, China University of Mining and Technology, Beijing, China
| | - Mei Shuai
- School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yu Ding
- Orthopedics, TCM Senior Department, The Sixth Medical Center of PLA General Hospital, Beijing, China
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Liu G, Huang W, Leng N, He P, Li X, Lin M, Lian Z, Wang Y, Chen J, Cai W. Comparative Biomechanical Stability of the Fixation of Different Miniplates in Restorative Laminoplasty after Laminectomy: A Finite Element Study. Bioengineering (Basel) 2024; 11:519. [PMID: 38790385 PMCID: PMC11117612 DOI: 10.3390/bioengineering11050519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/08/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024] Open
Abstract
A novel H-shaped miniplate (HSM) was specifically designed for restorative laminoplasties to restore patients' posterior elements after laminectomies. A validated finite element (FE) model of L2/4 was utilized to create a laminectomy model, as well as three restorative laminoplasty models based on the fixation of different miniplates after a laminectomy (the RL-HSM model, the RL-LSM model, and the RL-THM model). The biomechanical effects of motion and displacement on a laminectomy and restorative laminoplasty with three different shapes for the fixation of miniplates were compared under the same mechanical conditions. This study aimed to validate the biomechanical stability, efficacy, and feasibility of a restorative laminoplasty with the fixation of miniplates post laminectomy. The laminectomy model demonstrated the greatest increase in motion and displacement, especially in axial rotation, followed by extension, flexion, and lateral bending. The restorative laminoplasty was exceptional in preserving the motion and displacement of surgical segments when compared to the intact state. This preservation was particularly evident in lateral bending and flexion/extension, with a slight maintenance efficacy observed in axial rotation. Compared to the laminectomy model, the restorative laminoplasties with the investigated miniplates demonstrated a motion-limiting effect for all directions and resulted in excellent stability levels under axial rotation and flexion/extension. The greatest reduction in motion and displacement was observed in the RL-HSM model, followed by the RL-LSM model and then the RL-THM model. When comparing the fixation of different miniplates in restorative laminoplasties, the HSMs were found to be superior to the LSMs and THMs in maintaining postoperative stability, particularly in axial rotation. The evidence suggests that a restorative laminoplasty with the fixation of miniplates is more effective than a conventional laminectomy due to the biomechanical effects of restoring posterior elements, which helps patients regain motion and limit load displacement responses in the spine after surgery, especially in axial rotation and flexion/extension. Additionally, our evaluation in this research study could benefit from further research and provide a methodological and modeling basis for the design and optimization of restorative laminoplasties.
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Affiliation(s)
- Guoyin Liu
- Department of Orthopedics, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing 211166, China; (G.L.); (W.H.); (N.L.); (P.H.); (M.L.)
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Weiqian Huang
- Department of Orthopedics, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing 211166, China; (G.L.); (W.H.); (N.L.); (P.H.); (M.L.)
| | - Nannan Leng
- Department of Orthopedics, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing 211166, China; (G.L.); (W.H.); (N.L.); (P.H.); (M.L.)
| | - Peng He
- Department of Orthopedics, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing 211166, China; (G.L.); (W.H.); (N.L.); (P.H.); (M.L.)
| | - Xin Li
- Department of Orthopedics, Central Military Commission Joint Logistics Support Force 904th Hospital, Wuxi 214044, China;
| | - Muliang Lin
- Department of Orthopedics, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing 211166, China; (G.L.); (W.H.); (N.L.); (P.H.); (M.L.)
| | - Zhonghua Lian
- Xiamen Medical Device Research and Testing Center, Xiamen 361022, China;
| | - Yong Wang
- Outpatient Department of The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing 211166, China;
| | - Jianmin Chen
- Department of Orthopedics, The Affiliated Jinling Hospital of Nanjing Medical University, Nanjing 211166, China; (G.L.); (W.H.); (N.L.); (P.H.); (M.L.)
| | - Weihua Cai
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
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Liu R, He T, Wu X, Tan W, Yan Z, Deng Y. Biomechanical response of decompression alone in lower grade lumbar degenerative spondylolisthesis--A finite element analysis. J Orthop Surg Res 2024; 19:209. [PMID: 38561837 PMCID: PMC10983632 DOI: 10.1186/s13018-024-04681-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/15/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Previous studies have demonstrated the clinical efficacy of decompression alone in lower-grade spondylolisthesis. A higher rate of surgical revision and a lower rate of back pain relief was also observed. However, there is a lack of relevant biomechanical evidence after decompression alone for lower-grade spondylolisthesis. PURPOSE Evaluating the biomechanical characteristics of total laminectomy, hemilaminectomy, and facetectomy for lower-grade spondylolisthesis by analyzing the range of motion (ROM), intradiscal pressure (IDP), annulus fibrosus stress (AFS), facet joints contact force (FJCF), and isthmus stress (IS). METHODS Firstly, we utilized finite element tools to develop a normal lumbar model and subsequently constructed a spondylolisthesis model based on the normal model. We then performed total laminectomy, hemilaminectomy, and one-third facetectomy in the normal model and spondylolisthesis model, respectively. Finally, we analyzed parameters, such as ROM, IDP, AFS, FJCF, and IS, for all the models under the same concentrate force and moment. RESULTS The intact spondylolisthesis model showed a significant increase in the relative parameters, including ROM, AFS, FJCF, and IS, compared to the intact normal lumbar model. Hemilaminectomy and one-third facetectomy in both spondylolisthesis and normal lumbar models did not result in an obvious change in ROM, IDP, AFS, FJCF, and IS compared to the pre-operative state. Moreover, there was no significant difference in the degree of parameter changes between the spondylolisthesis and normal lumbar models after undergoing the same surgical procedures. However, total laminectomy significantly increased ROM, AFS, and IS and decreased the FJCF in both normal lumbar models and spondylolisthesis models. CONCLUSION Hemilaminectomy and one-third facetectomy did not have a significant impact on the segment stability of lower-grade spondylolisthesis; however, patients with LDS undergoing hemilaminectomy and one-third facetectomy may experience higher isthmus stress on the surgical side during rotation. In addition, total laminectomy changes the biomechanics in both normal lumbar models and spondylolisthesis models.
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Affiliation(s)
- Renfeng Liu
- Department of Spine Surgery, Central South University Third Xiangya Hospital, Changsha, China
| | - Tao He
- Department of Spine Surgery, Central South University Third Xiangya Hospital, Changsha, China
| | - Xin Wu
- Department of Spine Surgery, Central South University Third Xiangya Hospital, Changsha, China
| | - Wei Tan
- Department of Spine Surgery, Central South University Third Xiangya Hospital, Changsha, China
| | - Zuyun Yan
- Department of Spine Surgery, Central South University Third Xiangya Hospital, Changsha, China
| | - Youwen Deng
- Department of Spine Surgery, Central South University Third Xiangya Hospital, Changsha, China.
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Abbasi HR, Abd-Elsayed A, Storlie NR. Laminotomy. DECOMPRESSIVE TECHNIQUES 2024:67-75. [DOI: 10.1016/b978-0-323-87751-0.00017-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Anderson B, Shahidi B. The Impact of Spine Pathology on Posterior Ligamentous Complex Structure and Function. Curr Rev Musculoskelet Med 2023; 16:616-626. [PMID: 37870725 PMCID: PMC10733250 DOI: 10.1007/s12178-023-09873-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 10/24/2023]
Abstract
PURPOSE OF REVIEW Spinal ligament is an important component of the spinal column in mitigating biomechanical stress. Particularly the posterior ligamentous complex, which is composed of the ligamentum flavum, interspinous, and supraspinous ligaments. However, research characterizing the biomechanics and role of ligament health in spinal pathology and clinical context are scarce. This article provides a comprehensive review of the implications of spinal pathology on the structure, function, and biomechanical properties of the posterior ligamentous complex. RECENT FINDINGS Current research characterizing biomechanical properties of the posterior ligamentous complex is primarily composed of cadaveric studies and finite element modeling, and more recently incorporating patient-specific anatomy into finite element models. The ultimate goal of current research is to understand the relative contributions of these ligamentous structures in healthy and pathological spine, and whether preserving ligaments may play an important role in spinal surgical techniques. At baseline, posterior ligamentous complex structures account for 30-40% of spinal stability, which is highly dependent on the intrinsic biomechanical properties of each ligament. Biomechanics vary widely with pathology and following rigid surgical fixation techniques and are generally maladaptive. Often secondary to morphological changes in the setting of spinal pathology, but morphological changes in ligament may also serve as a primary pathology. Biomechanical maladaptations of the spinal ligament adversely influence overall spinal column integrity and ultimately predispose to increased risk for surgical failure and poor clinical outcomes. Future research is needed, particularly in living subjects, to better characterize adaptations in ligaments that can provide targets for improved treatment of spinal pathology.
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Affiliation(s)
- Bradley Anderson
- Department of Orthopaedic Surgery, The University of California San Diego, 9500 Gilman Dr., MC0863, La Jolla, San Diego, CA, 92093, USA
| | - Bahar Shahidi
- Department of Orthopaedic Surgery, The University of California San Diego, 9500 Gilman Dr., MC0863, La Jolla, San Diego, CA, 92093, USA.
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Xue Y, Li S, Wang Y, Zhang H, Cheng L, Wu Y, Wang Q, Wang D, Zou T, Shen J. Unilateral Modified Posterior Lumbar Interbody Fusion Combined With Contralateral Lamina Fenestration Treating Severe Lumbarspinal Stenosis: A Retrospective Clinical Study. Surg Innov 2023; 30:73-83. [PMID: 35505578 DOI: 10.1177/15533506221096016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Study design: Retrospective study. Objectives: The traditional PLIF is routinely utilized in severe lumbar spinal stenosis to relief the nerve compression. Nevertheless, the removal of posterior tension-band structure and the denervation and atrophy of the paraspinal muscle affect the clinical efficacy. Therefore, unilateral modified PLIF combined with contralateral fenestration was performed to overcome above-mentioned drawbacks. Methods: 32 modified PLIF and 33 traditional PLIF cases were retrospectively included. Operation time, length of stay (LOS) and blood loss were recorded. VAS of low back pain and leg pain, ODI and Sf-36 score including physical function and body pain were assessed. Fusion rate, lumbar lordosis (LL), intervertebral angle (IVA) and intervertebral height index (IHI) were evaluated radiologically. Results: Modified group possessed less blood loss, shorter operation time and less LOS. Compared with traditional group, the VAS of back pain was lower at 6 months postoperatively (P < .05) and the ODI score was lower at 3 months postoperatively (P < .05) in modified group. Modified group exhibited better physical function 3 months postoperatively and lower body pain 6 months postoperatively in Sf-36 score (P < .05). No statistic difference in LL, IVA, IHI and fusion rate were observed between both groups. Conclusions: Our modified PLIF combining with contralateral fenestration procedure exhibited particular advantages in comparison to traditional PLIF. The preservation of posterior tension-band structure facilitates to less low back pain, low complication rate and early functional recovery.
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Affiliation(s)
- Yulun Xue
- Department of Orthopeadic Surgery, the Affiliated Suzhou Hospital of Nanjing Medical University, Gusu School, Nanjing Medical University, 117958Suzhou Municipal Hospital, Suzhou, China.,Department of Orthopeadic Surgery, Changshu Second People's Hospital, the Affiliated Changshu Hospital of Xuzhou Medical University, the Fifth Hospital Affiliated to Yangzhou University, Changshu, China
| | - Suoyuan Li
- Department of Orthopeadic Surgery, the Affiliated Suzhou Hospital of Nanjing Medical University, Gusu School, Nanjing Medical University, 117958Suzhou Municipal Hospital, Suzhou, China
| | - Yefeng Wang
- Department of Orthopeadic Surgery, the Affiliated Suzhou Hospital of Nanjing Medical University, Gusu School, Nanjing Medical University, 117958Suzhou Municipal Hospital, Suzhou, China
| | - Hong Zhang
- Department of Orthopeadic Surgery, the Affiliated Suzhou Hospital of Nanjing Medical University, Gusu School, Nanjing Medical University, 117958Suzhou Municipal Hospital, Suzhou, China
| | - Liang Cheng
- Department of Orthopeadic Surgery, the Affiliated Suzhou Hospital of Nanjing Medical University, Gusu School, Nanjing Medical University, 117958Suzhou Municipal Hospital, Suzhou, China
| | - Yinghui Wu
- Department of Orthopeadic Surgery, the Affiliated Suzhou Hospital of Nanjing Medical University, Gusu School, Nanjing Medical University, 117958Suzhou Municipal Hospital, Suzhou, China
| | - Qiang Wang
- Department of Orthopeadic Surgery, the Affiliated Suzhou Hospital of Nanjing Medical University, Gusu School, Nanjing Medical University, 117958Suzhou Municipal Hospital, Suzhou, China
| | - Donglai Wang
- Department of Orthopeadic Surgery, the Affiliated Suzhou Hospital of Nanjing Medical University, Gusu School, Nanjing Medical University, 117958Suzhou Municipal Hospital, Suzhou, China
| | - Tianming Zou
- Department of Orthopeadic Surgery, the Affiliated Suzhou Hospital of Nanjing Medical University, Gusu School, Nanjing Medical University, 117958Suzhou Municipal Hospital, Suzhou, China
| | - Jun Shen
- Department of Orthopeadic Surgery, the Affiliated Suzhou Hospital of Nanjing Medical University, Gusu School, Nanjing Medical University, 117958Suzhou Municipal Hospital, Suzhou, China
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11
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Jamieson A, Letchuman V, Tan LA. Commentary: Microsurgical Tubular Resection of Intradural Extramedullary Spinal Tumors With 3-Dimensional-Navigated Localization. Oper Neurosurg (Hagerstown) 2022; 23:e405-e406. [PMID: 36251437 DOI: 10.1227/ons.0000000000000451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Alysha Jamieson
- Department of Neurological Surgery, University of California, San Francisco Medical Center, San Francisco, California, USA
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12
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McGrath LB, Kirnaz S, Goldberg JL, Sommer F, Medary B, Hussain I, Härtl R. Microsurgical Tubular Resection of Intradural Extramedullary Spinal Tumors With 3-Dimensional-Navigated Localization. Oper Neurosurg (Hagerstown) 2022; 23:e245-e255. [PMID: 36103347 DOI: 10.1227/ons.0000000000000365] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The safety and efficacy of minimally invasive spine surgical (MISS) approaches have stimulated interest in adapting MISS principles for more complex pathology including intradural extramedullary (IDEM) tumors. No study has characterized a repeatable approach integrating the MISS surgical technique and 3-dimensional intraoperative navigated localization for the treatment of IDEM tumors. OBJECTIVE To describe a safe and reproducible technical guide for the navigated MISS technique for the treatment of benign intradural and extradural spinal tumors. METHODS Retrospective review of prospectively collected data on 20 patients who underwent navigated microsurgical tubular resection of intradural extramedullary tumors over a 5-year period. We review our approach to patient selection and report demographic and outcomes data for the cohort. RESULTS Our experience demonstrates technical feasibility and safety with a 100% rate of gross total resection with no patients demonstrating recurrence during an average follow-up of 20.2 months and no instances of perioperative complications. We demonstrate favorable outcomes regarding blood loss, operative duration, and hospital length of stay. CONCLUSION Navigated localization and microsurgical tubular resection of IDEM tumors is safe and effective. Adherence to MISS principles and thoughtful patient selection facilitate successful management of these patients.
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Affiliation(s)
- Lynn B McGrath
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, USA
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13
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Kitab SA, Wakefield AE, Benzel EC. Postlaminectomy lumbopelvic sagittal changes in patients with developmental lumbar spinal stenosis grouped into Roussouly lumbopelvic sagittal profiles: 2- to 10-year prospective follow-up. J Neurosurg Spine 2022; 36:695-703. [PMID: 34826807 DOI: 10.3171/2021.8.spine21797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Roussouly lumbopelvic sagittal profiles are associated with distinct pathologies or distinct natural histories and prognoses. The associations between developmental lumbar spinal stenosis (DLSS) and native lumbopelvic sagittal profiles are unknown. Moreover, the relative effects of multilevel decompression on lumbar sagittal alignment, geometrical parameters of the pelvis, and compensatory mechanisms for each of the Roussouly subtypes are unknown. This study aimed to explore the association between DLSS and native lumbar lordosis (LL) subtypes. It also attempts to understand the natural history of postlaminectomy lumbopelvic sagittal changes and compensatory mechanisms for each of the Roussouly subtypes and to define the critical lumbar segment or specific lordosis arc that is recruited after relief of the stenosis effect. METHODS A total of 418 patients with multilevel DLSS were grouped into various Roussouly subtypes, and lumbopelvic sagittal parameters were prospectively compared at follow-up intervals of preoperative to < 2 years, 2 to < 5 years, and 5 to ≥ 10 years after laminectomy. The variables analyzed included LL, upper lordosis arc from L1 to L4, lower lordosis arc from L4 to S1, and segmental lordosis from L1 to S1. Pelvic parameters included pelvic incidence, sacral slope, pelvic tilt, and pelvic incidence minus LL values. RESULTS Of the 329 patients who were followed up throughout this study, 33.7% had Roussouly type 1 native lordosis, whereas the incidence rates of types 2, 3, and 4 were 33.4%, 21.9%, and 10.9%, respectively. LL was not reduced in any of the Roussouly subtypes after multilevel decompressions. Instead, LL increased by 4.5° (SD 11.9°-from 27.3° [SD 11.5°] to 31.8° [SD 9.8°]) in Roussouly type 1 and by 3.1° (SD 11.6°-from 41.3° [SD 9.5°] to 44.4° [SD = 9.7°]) in Roussouly type 2. The other Roussouly types showed no significant changes. Pelvic tilt decreased significantly-by 2.8°, whereas sacral slope increased significantly-by 2.9° in Roussouly type 1 and by 1.7° in Roussouly type 2. The critical lumbar segment that recruits LL differs between Roussouly subtypes. Increments and changes were sustained until the final follow-up. CONCLUSIONS The study findings are important in predicting patient prognosis, LL evolution, and the need for prophylactic or corrective deformity surgery. Multilevel involvement in DLSS and the high prevalence of Roussouly types 1 and 2 suggest that spinal canal dimensions are closely linked to the developmental evolution of LL.
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Affiliation(s)
| | - Andrew E Wakefield
- 2Connecticut Neurosurgery and Spine Associates, Windsor, Connecticut; and
| | - Edward C Benzel
- 3Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
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Stable Low-Grade Degenerative Spondylolisthesis Does Not Compromise Clinical Outcome of Minimally Invasive Tubular Decompression in Patients with Spinal Stenosis. Medicina (B Aires) 2021; 57:medicina57111270. [PMID: 34833488 PMCID: PMC8622409 DOI: 10.3390/medicina57111270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/04/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives: In recent literature, the routine addition of arthrodesis to decompression for lumbar spinal stenosis (LSS) with concomitant stable low-grade degenerative spondylolisthesis remains controversial. The purpose of this study is to compare the clinical outcome, complication and re-operation rates following minimally invasive (MIS) tubular decompression without arthrodesis in patients suffering from LSS with or without concomitant stable low-grade degenerative spondylolisthesis. Materials and Methods: This study is a retrospective review of prospectively collected data. Ninety-six consecutive patients who underwent elective MIS lumbar decompression with a mean follow-up of 27.5 months were included in the study. The spondylolisthesis (S) group comprised 53 patients who suffered from LSS with stable degenerative spondylolisthesis, and the control (N) group included 43 patients suffering from LSS without spondylolisthesis. Outcome measures included complications and revision surgery rates. Pre- and post-operative visual analog scale (VAS) for both back and leg pain was analyzed, and the Oswestry Disability Index (ODI) was used to evaluate functional outcome. Results: The two groups were comparable in most demographic and preoperative variables. VAS for back and leg pain improved significantly following surgery in both groups. Both groups showed significant improvement in their ODI scores, at one and two years postoperatively. The average length of hospital stay was significantly higher in patients with spondylolisthesis (p-value< 0.01). There was no significant difference between the groups in terms of post-operative complications rates or re-operation rates. Conclusions: Our results indicate that MIS tubular decompression may be an effective and safe procedure for patients suffering from LSS, with or without degenerative stable spondylolisthesis.
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15
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Louie PK, Vaishnav AS, Gang CH, Urakawa H, Sato K, Chaudhary C, Lee R, Mok JK, Sheha E, Lafage V, Qureshi SA. Development and Initial Internal Validation of a Novel Classification System for Perioperative Expectations Following Minimally Invasive Degenerative Lumbar Spine Surgery. Clin Spine Surg 2021; 34:E537-E544. [PMID: 34459472 DOI: 10.1097/bsd.0000000000001246] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 06/23/2021] [Indexed: 12/17/2022]
Abstract
STUDY DESIGN This was a prospective consecutive clinical cohort study. OBJECTIVE The purpose of our study was to develop and provide an initial internal validation of a novel classification system that can help surgeons and patients better understand their postoperative course following the particular minimally invasive surgery (MIS) and approach that is utilized. SUMMARY OF BACKGROUND DATA Surgeons and patients are often attracted to the option of minimally invasive spine surgery because of the perceived improvement in recovery time and postsurgical pain. A classification system based on the impact of the surgery and surgical approach(es) on postoperative recovery can be particularly helpful. METHODS Six hundred thirty-one patients who underwent MIS lumbar/thoracolumbar surgery for degenerative conditions of the spine were included. Perioperative outcomes-operative time, estimated blood loss, postsurgical length of stay (LOS), 90-day complications, postoperative day zero narcotic requirement [in Morphine Milligram Equivalent (MME)], and need for intravenous patient-controlled analgesia (IV PCA). RESULTS Postoperative LOS and postoperative narcotic use were deemed most clinically relevant, thus selected as primary outcomes. Type of surgery was significantly associated with all outcomes (P<0.0001), except intraoperative complications. Number of levels for fusion was significantly associated with operative time, in-hospital complications, 24 hours oral MME, and the need for IV PCA and LOS (P<0.0001). Number of surgical approaches for lumbar fusion was significantly associated with operative time, 24 hours oral MME, need for IV PCA and LOS (P<0.001). Based on these parameters, the following classification system ("Qureshi-Louie classification" for MIS degenerative lumbar surgery) was devised: (1) Decompression-only; (2) Fusion-1 and 2 levels, 1 approach; (3) Fusion-1 level, 2 approaches; (4) Fusion-2 levels, 2 approaches; (5) Fusion-3+ levels, 2 approaches. CONCLUSIONS We present a novel classification system and initial internal validation to describe the perioperative expectations following various MIS surgeries in the degenerative lumbar spine. This initial description serves as the basis for ongoing external validation.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Evan Sheha
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
| | | | - Sheeraz A Qureshi
- Hospital for Special Surgery
- Weill Cornell Medical College, New York, NY
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16
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Implications of Different Types of Decompression Spinal Stenosis Surgical Procedures on the Biomechanics of Lumbar Spine. J Med Biol Eng 2021. [DOI: 10.1007/s40846-020-00580-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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17
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Cheng BC, Swink I, Yusufbekov R, Birgelen M, Ferrara L, Lewandrowski KU, Coric D. Current Concepts of Contemporary Expandable Lumbar Interbody Fusion Cage Designs, Part 1: An Editorial on Their Biomechanical Characteristics. Int J Spine Surg 2020; 14:S63-S67. [PMID: 33122179 PMCID: PMC7735463 DOI: 10.14444/7128] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Bidirectional expandable designs for lumbar interbody fusion cages are the latest iteration of expandable spacers employed to address some of the common problems inherent to static interbody fusion cages. OBJECTIVE To describe the rationales for contemporary bidirectional, multimaterial expandable lumbar interbody fusion cage designs to achieve in situ expansion for maximum anterior column support while decreasing insertion size during minimal-access surgeries. METHODS The authors summarize the current concepts behind expandable spinal fusion open architecture cage designs focusing on advanced minimally invasive spinal surgery techniques, such as endoscopy. A cage capable of bidirectional expansion in both height and width to address constrained surgical access problems was of particular interest to the authors while they analyzed the relationship between implant material stiffness and geometric design regarding the risk of subsidence and reduced graft loading. CONCLUSIONS Biomechanical advantages of new bidirectional, multimaterial expandable interbody fusion cages allow insertion through minimal surgical access and combine the advantages of proven device configurations and advanced material selection. The final construct stiffness is sufficient to provide immediate anterior column support while accommodating reduced sizes required for minimally invasive surgery applications. LEVEL OF EVIDENCE 7.
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Affiliation(s)
- Boyle C Cheng
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Isaac Swink
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | - Michele Birgelen
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Lisa Ferrara
- OrthoKinetic Technologies LLC, Southport, North Carolina
| | - Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona and Surgical Institute of Tucson, Arizona
| | - Domagoj Coric
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
- Atrium Musculoskeletal Institute, Charlotte, North Carolina
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18
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Kim SK, Ryu S, Kim ES, Lee SH, Lee SC. Radiologic Efficacy and Patient Satisfaction after Minimally Invasive Unilateral Laminotomy and Bilateral Decompression in Patients with Lumbar Spinal Stenosis: A Retrospective Analysis. J Neurol Surg A Cent Eur Neurosurg 2020; 81:475-483. [PMID: 32413931 DOI: 10.1055/s-0040-1701621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND STUDY AIMS Lumbar spinal stenosis (LSS) is the most common spinal disease in older adults. Although surgical modalities are recommended in patients who are unresponsive to conservative treatment, the most appropriate minimally invasive surgical procedure for patients with LSS remains controversial. Moreover, few previous studies have focused on patient-centered outcomes with radiologic correlation. In the present study, we aimed to investigate radiologic efficacy and patient satisfaction following bilateral decompression via unilateral laminotomy. MATERIALS AND METHODS We performed a retrospective analysis of radiologic efficacy and patient satisfaction in a series of surgical patients treated at our institution. We classified patients into two groups based on the primary pathology (i.e., central or lateral recess stenosis). Medical records were analyzed retrospectively for radiologic outcomes and clinical parameters including pain and changes in quality of life. Data related to outcomes were collected at 2 weeks, 3 months, and 12 months after surgery in the outpatient clinic. RESULTS Among the 122 patients enrolled in this study, 51 had central spinal stenosis; 71 had lateral recess stenosis. Radiologically, we observed significant improvements in the anteroposterior diameter and cross-sectional area of the dural sac (central stenosis) and the lateral width of the central canal and depth of the lateral recess (lateral recess stenosis). Two weeks and 12 months after the surgical procedure, we observed significant improvements in the extent of symptoms, patient satisfaction, and quality of life (including physical function). CONCLUSION Our findings suggest that bilateral decompression via a unilateral approach shows improved radiologic outcomes, varying based on the type of stenosis. Furthermore, patient satisfaction significantly improved regardless of the type of disease.
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Affiliation(s)
- Seung-Kook Kim
- Himchan UHS Joint and Spine Centre, University Hospital Sharjah, Sharjah, United Arab Emirates.,Department of Pharmaceutical Medicine and Regulatory Sciences, College of Medicine and Pharmacy, Yonsei University, Incheon, Republic of Korea.,Joint and Arthritis Research, Orthopaedic Surgery, Himchan Hospital, Seoul, Republic of Korea
| | - Sungmo Ryu
- Department of Neurosurgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun-Sang Kim
- Department of Neurosurgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sun-Ho Lee
- Department of Neurosurgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Su-Chan Lee
- Joint and Arthritis Research, Orthopaedic Surgery, Himchan Hospital, Seoul, Republic of Korea
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19
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Ahuja S, Moideen AN, Dudhniwala AG, Karatsis E, Papadakis L, Varitis E. Lumbar stability following graded unilateral and bilateral facetectomy: A finite element model study. Clin Biomech (Bristol, Avon) 2020; 75:105011. [PMID: 32335473 DOI: 10.1016/j.clinbiomech.2020.105011] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 04/02/2020] [Accepted: 04/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Excision of excessive amount of facet joint during lumbar discectomy or decompression can cause segmental instability of the lumbar spine. This study was performed to assess the segmental instability, facet joint loading and intradiscal pressure following graded lumbar facetectomy. This biomechanical study was performed using a verified and validated L3-S1 finite element model. METHODS Nine scenarios were analysed. Intact model as control, 30%, 45%, 60% and complete facet joint excision in unilateral and bilateral setting. The effect of progressive graded facetectomy of L4-L5 on the segmental mobility, facet loading and intradiscal pressure was assessed. FINDINGS In comparison with control 30% excision of the facet joint mainly caused increase in mediolateral mobility. With 45% excision of the facet joint there was increase in both anteroposterior and mediolateral mobility, this was worse in bilateral and unilateral models respectively. This worsened with larger facet excision scenarios. Facet load increased significantly on extension with excision of 45% & 60% unilaterally and 100% bilaterally. Flexion produced rise in intradiscal pressure in all scenarios. INTERPRETATION The increased spinal mobility, facet loading and intradiscal pressure with more than 30% facetectomy highlights the importance of preserving the facets during decompression thereby safeguarding accelerated degeneration of these segments and iatrogenic segmental instability. The findings from this study could also potentially explain the correlation between spinal instability, disc degeneration and facet joint arthrosis as noted in clinical studies.
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Affiliation(s)
- S Ahuja
- Wales Centre for Spinal Surgery and Trauma, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom
| | - A N Moideen
- Wales Centre for Spinal Surgery and Trauma, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom.
| | - A G Dudhniwala
- Wales Centre for Spinal Surgery and Trauma, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom
| | - E Karatsis
- Group Leader of Biomechanics, BETA CAE Systems S.A., 54005 Thessaloniki, Greece.
| | - L Papadakis
- Laboratory for Biomaterials and Computational Mechanics, Department of Mechanical Engineering, University of Western Macedonia, Kozani, Greece
| | - E Varitis
- Laboratory for Biomaterials and Computational Mechanics, Department of Mechanical Engineering, University of Western Macedonia, Kozani, Greece.
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20
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Korge A, Mehren C, Ruetten S. [Minimally invasive decompression techniques for spinal cord stenosis]. DER ORTHOPADE 2019; 48:824-830. [PMID: 31053867 DOI: 10.1007/s00132-019-03732-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Lumbar spinal canal stenosis is frequently found among elderly patients and significantly limits their quality of life. Non-surgical therapy is an initial treatment option; however, it does not eliminate the underlying pathology. Surgical decompression of the spinal canal has now become the treatment of choice. OBJECTIVE Minimalization of surgical approach strategies with maintaining sufficient decompression of the spinal canal and avoiding disadvantages of macrosurgical techniques, monolateral paravertebral approach with bilateral intraspinal decompression, specific surgical techniques. MATERIALS AND METHODS Minimally invasive decompression techniques using a microscope or an endoscope are presented and different surgical strategies depending on both the extent (mono-, bi-, and multisegmental) and the location of the stenosis (intraspinal central, lateral recess, foraminal) are described. RESULTS Minimally invasive microscopic or endoscopic decompression procedures enable sufficient widening of the spinal canal. Disadvantages of macrosurgical procedures (e. g., postoperative instability) can be avoided. The complication spectrum overlaps partially with that of macrosurgical interventions, albeit with significantly less marked severity. Subjective patient outcome is clearly improved. CONCLUSIONS Referring to modern minimally invasive decompression procedures, surgery of lumbar spinal canal stenosis represents a rational and logical treatment alternative, since causal treatment of the pathology is only possible with surgery.
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Affiliation(s)
- A Korge
- Wirbelsäulenzentrum, Schön Klinik München Harlaching, Harlachinger Str. 51, 81547, München, Deutschland. .,Lehrkrankenhaus und Institut für Wirbelsäulenforschung der Paracelsus Universität Salzburg, PMU, Salzburg, Österreich.
| | - C Mehren
- Wirbelsäulenzentrum, Schön Klinik München Harlaching, Harlachinger Str. 51, 81547, München, Deutschland.,Lehrkrankenhaus und Institut für Wirbelsäulenforschung der Paracelsus Universität Salzburg, PMU, Salzburg, Österreich
| | - S Ruetten
- Zentrum für Wirbelsäulenchirurgie und Schmerztherapie, Zentrum für Orthopädie und Unfallchirurgie, St. Elisabeth Gruppe - Katholische Kliniken Rhein-Ruhr, St. Anna Hospital Herne/Universitätsklinikum Marien Hospital Herne/Marien Hospital Witten, Herne, Deutschland
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Lo HJ, Chen CS, Chen HM, Yang SW. Application of an interspinous process device after minimally invasive lumbar decompression could lead to stress redistribution at the pars interarticularis: a finite element analysis. BMC Musculoskelet Disord 2019; 20:213. [PMID: 31092237 PMCID: PMC6518805 DOI: 10.1186/s12891-019-2565-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 04/11/2019] [Indexed: 12/21/2022] Open
Abstract
Background An interspinous process device, the Device for Intervertebral Assisted Motion (DIAM™) designed to treat lumbar neurogenic disease secondary to the lumbar spinal stenosis, it provides dynamic stabilization after minimally invasive (MI) lumbar decompression. The current study was conducted using an experimentally validated L1-L5 spinal finite element model (FEM) to evaluate the limited decompression on range of motion (ROM) and stress distribution on a neural arch implanted with the DIAM. Methods The study simulated bilateral laminotomies with partial discectomy at L3-L4, as well as unilateral and bilateral laminotomies with partial discectomy combined with implementation of the DIAM at L3-L4. The ROM and maximum von Mises stresses in flexion, extension, lateral bending, and axial torsion were analyzed in response to the hybrid protocol in comparison with the intact model. Results The investigation revealed that decreased ROM, intradiscal stress, and facet joint force at the implant level, but considerably increased stress at the pars interarticularis were found during flexion and torsion at the L4, as well as during extension, lateral bending, and torsion at the L3, when the DIAM was implanted compared with the defect model. Conclusion The results demonstrate that the DIAM may be beneficial in reducing the symptoms of stress-induced low back pain. Nevertheless, the results also suggest that a surgeon should be cognizant of the stress redistribution at the pars interarticularis results from MI decompression plus the application of the interspinous process device.
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Affiliation(s)
- Hao-Ju Lo
- Department of Biomedical Engineering, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan.,Department of Orthopedic Surgery, Dali Branch, Jen-Ai Hospital, 483 Dong Rong Rd, Dali, Taichung, Taiwan
| | - Chen-Sheng Chen
- Department of Physical Therapy and Assistive Technology, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan
| | - Hung-Ming Chen
- Department of Orthopedic Surgery, Renai Branch, Taipei City Hospital, No. 10, Section 4, Ren'ai Road, Da'an District, Taipei City, 106, Taiwan
| | - Sai-Wei Yang
- Department of Biomedical Engineering, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, 11221, Taiwan.
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22
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Pietrantonio A, Trungu S, Famà I, Forcato S, Miscusi M, Raco A. Long-term clinical outcomes after bilateral laminotomy or total laminectomy for lumbar spinal stenosis: a single-institution experience. Neurosurg Focus 2019; 46:E2. [DOI: 10.3171/2019.2.focus18651] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 02/26/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVELumbar spinal stenosis (LSS) is the most common spinal disease in the geriatric population, and is characterized by a compression of the lumbosacral neural roots from a narrowing of the lumbar spinal canal. LSS can result in symptomatic compression of the neural elements, requiring surgical treatment if conservative management fails. Different surgical techniques with or without fusion are currently treatment options. The purpose of this study was to provide a description of the long-term clinical outcomes of patients who underwent bilateral laminotomy compared with total laminectomy for LSS.METHODSThe authors retrospectively reviewed all the patients treated surgically by the senior author for LSS with total laminectomy and bilateral laminotomy with a minimum of 10 years of follow-up. Patients were divided into 2 treatment groups (total laminectomy, group 1; and bilateral laminotomy, group 2) according to the type of surgical decompression. Clinical outcomes measures included the visual analog scale (VAS), the 36-Item Short-Form Health Survey (SF-36) scores, and the Oswestry Disability Index (ODI). In addition, surgical parameters, reoperation rate, and complications were evaluated in both groups.RESULTSTwo hundred fourteen patients met the inclusion and exclusion criteria (105 and 109 patients in groups 1 and 2, respectively). The mean age at surgery was 69.5 years (range 58–77 years). Comparing pre- and postoperative values, both groups showed improvement in ODI and SF-36 scores; at final follow-up, a slightly better improvement was noted in the laminotomy group (mean ODI value 22.8, mean SF-36 value 70.2), considering the worse preoperative scores in this group (mean ODI value 70, mean SF-36 value 38.4) with respect to the laminectomy group (mean ODI 68.7 vs mean SF-36 value 36.3), but there were no statistically significant differences between the 2 groups. Significantly, in group 2 there was a lower incidence of reoperations (15.2% vs 3.7%, p = 0.0075).CONCLUSIONSBilateral laminotomy allows adequate and safe decompression of the spinal canal in patients with LSS; this technique ensures a significant improvement in patients’ symptoms, disability, and quality of life. Clinical outcomes are similar in both groups, but a lower incidence of complications and iatrogenic instability has been shown in the long term in the bilateral laminotomy group.
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Affiliation(s)
- Andrea Pietrantonio
- 1Department of Neuroscience, Mental Health, and Sense Organs, Faculty of Medicine and Psychology, ‘‘Sapienza” University of Rome, Sant’Andrea Hospital, Rome
- 3Neurosurgery Unit, Santa Maria Goretti Hospital, Latina, Italy
| | - Sokol Trungu
- 1Department of Neuroscience, Mental Health, and Sense Organs, Faculty of Medicine and Psychology, ‘‘Sapienza” University of Rome, Sant’Andrea Hospital, Rome
- 2Neurosurgery Unit, Cardinale G. Panico Hospital, Tricase; and
| | - Isabella Famà
- 1Department of Neuroscience, Mental Health, and Sense Organs, Faculty of Medicine and Psychology, ‘‘Sapienza” University of Rome, Sant’Andrea Hospital, Rome
| | - Stefano Forcato
- 1Department of Neuroscience, Mental Health, and Sense Organs, Faculty of Medicine and Psychology, ‘‘Sapienza” University of Rome, Sant’Andrea Hospital, Rome
- 2Neurosurgery Unit, Cardinale G. Panico Hospital, Tricase; and
| | - Massimo Miscusi
- 1Department of Neuroscience, Mental Health, and Sense Organs, Faculty of Medicine and Psychology, ‘‘Sapienza” University of Rome, Sant’Andrea Hospital, Rome
| | - Antonino Raco
- 1Department of Neuroscience, Mental Health, and Sense Organs, Faculty of Medicine and Psychology, ‘‘Sapienza” University of Rome, Sant’Andrea Hospital, Rome
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Ma Z, Huang S, Sun J, Li F, Sun J, Pi G. Risk factors for upper adjacent segment degeneration after multi-level posterior lumbar spinal fusion surgery. J Orthop Surg Res 2019; 14:89. [PMID: 30922408 PMCID: PMC6437868 DOI: 10.1186/s13018-019-1126-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/11/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Posterior lumbar spinal fusion has been widely used in degenerative lumbar stenosis, but adjacent segment degeneration (ASD) was common. Researchers have found many risk factors for ASD after one or two levels of surgery, but few clinical studies focused on multi-level surgery. The purpose of this study was to clarify risk factors for upper ASD after multi-level posterior lumbar spinal fusion. METHODS A retrospective study was performed on the clinical data of 71 patients with degenerative lumbar stenosis who underwent multi-level (at least 3 levels) posterior lumbar spinal fusion from January 2013 to December 2016. Two groups were divided according to lamina and posterior ligamentous complex (PLC) maintenance of proximal fixed vertebrae in surgery. In the 22 patients of group A, the proximal fixed vertebral lamina and PLC were not resected, and in the 49 patients of group B, the proximal fixed vertebral lamina and PLC were resected completely. Age, sex, body mass index (BMI), number of fixed vertebrae and fused levels, spinopelvic parameters, coronal Cobb angle, and modified Pfirrmann grading system were measured for each patient. A Cox proportional hazards model was used to analyze risk factors for upper ASD. RESULTS No symptomatic ASD was found during the follow-up period. Patients who underwent proximal fixed vertebral lamina and PLC resection had a significantly higher percentage of radiographic ASD (P = 0.042). The Cox proportional hazards model showed that age, sex, BMI, preoperative lumbar lordosis, sacral slope, pelvic tilt, coronal Cobb angle, number of fixed vertebrae, and interbody fusion levels had no significant differences for radiographic ASD. But a preoperative modified Pfirrmann grade higher than 3, a high degree of preoperative pelvic incidence, and more decompressed levels had statistical significance (P = 0.024, 0.041, and 0.008, respectively). CONCLUSIONS A preoperative modified Pfirrmann grade higher than 3, a high degree of preoperative pelvic incidence, and more decompressed levels might be risk factors for upper radiographic ASD after multi-level posterior lumbar spinal fusion surgery.
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Affiliation(s)
- Zhaoxin Ma
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, No.1 Jianshe East Road, Zhengzhou, 450052, Henan, China
| | - Shilei Huang
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, No.1 Jianshe East Road, Zhengzhou, 450052, Henan, China
| | - Jianguang Sun
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, No.1 Jianshe East Road, Zhengzhou, 450052, Henan, China
| | - Feng Li
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, No.1 Jianshe East Road, Zhengzhou, 450052, Henan, China
| | - Jianhao Sun
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, No.1 Jianshe East Road, Zhengzhou, 450052, Henan, China
| | - Guofu Pi
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, No.1 Jianshe East Road, Zhengzhou, 450052, Henan, China.
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Li Y, Wang H, Cui W, Zhou P, Li C, Xiao W, Hu B, Li F. [Long-term effectiveness of posterior lumbar interbody fusion of retaining posterior ligamentous complex]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:56-60. [PMID: 30644261 PMCID: PMC8337237 DOI: 10.7507/1002-1892.201809073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/09/2018] [Indexed: 11/03/2022]
Abstract
Objective To compare the long-term effectiveness of wheather posterior ligamentous complex (PLC) preserved between posterior fenestration decompression interbody fusion and posterior total laminectomy interbody fusion. Methods The clinical data of 89 patients who suffered from single segmental degenerative diseases of lower lumbar spine and followed up more than 10 years after receiving lumbar spinal fusion between January 2000 and January 2005 were retrospectively analysed. The patients were divided into two groups according to the different surgical methods, the 33 patients in group A were treated with posterior lumbar fenestration decompression, interbody fusion, and internal fixation, while 56 patients in group B were treated with posterior total laminectomy resection decompression, interbody fusion, and internal fixation. There was no significant difference in gender, age, body mass index, type of lesion, disease duration, lesion segment, and preoperative Japanese Orthopedic Association (JOA) score, visual analogue scale (VAS) score, and Cobb angle of lumbar lordosis between the two groups ( P>0.05). The effectiveness was evaluated by JOA score, and the improvement of pain was evaluated by VAS score. The incidence of adjacent segment degeneration (ASD) at last follow-up was recorded. Results Both groups were followed up 10-17 years (mean, 12.6 years). There were 3 cases (9.1%) in group A and 5 cases (8.9%) in group B complicated with cerebrospinal fluid leakage, showing no significant difference ( χ2=0.001, P=0.979). There was no complication such as infection, nerve root injury, internal plant loosening or transposition in both groups. Intervertebral fusion was satisfactory in both groups. The fusion time in groups A and B was (3.4±1.2) months and (3.7±1.6) months respectively, and there was no significant difference between the two groups ( t=0.420, P=0.676). At last follow-up, the JOA score and VAS score of the two groups were significantly improved when compared with preoperative ones ( P<0.05); there was no significant difference in Cobb angle of lumbar lordosis before and after operation in group A ( t=0.293, P=0.772), but the Cobb angle of lumbar lordosis in group B was significantly lost at last follow-up ( t=14.920, P=0.000). At last follow-up, the VAS score and Cobb angle of lumbar lordosis in group A were significantly superior to those in group B ( P<0.05); there was no significant difference in JOA score between the two groups ( t=0.217, P=0.828). There were 3 cases (9.1%) in group A and 21 cases (37.5%) in group B complicated with ASD, showing significant difference between the two groups ( χ2=8.509, P=0.004). Conclusion Long-term effectiveness of both groups was satisfactory, but in terms of maintaining lumbar lordosis and reducing the incidence of ASD, the lumbar fusion retaining PLC is superior to total laminectomy and lumbar fusion removing PLC.
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Affiliation(s)
- Yuwei Li
- Department of Spine Surgery, Luohe Central Hospital, Luohe Henan, 462000,
| | - Haijiao Wang
- Department of Spine Surgery, Luohe Central Hospital, Luohe Henan, 462000, P.R.China
| | - Wei Cui
- Department of Spine Surgery, Luohe Central Hospital, Luohe Henan, 462000, P.R.China
| | - Peng Zhou
- Department of Spine Surgery, Luohe Central Hospital, Luohe Henan, 462000, P.R.China
| | - Cheng Li
- Department of Spine Surgery, Luohe Central Hospital, Luohe Henan, 462000, P.R.China
| | - Wei Xiao
- Department of Spine Surgery, Luohe Central Hospital, Luohe Henan, 462000, P.R.China
| | - Bingtao Hu
- Department of Spine Surgery, Luohe Central Hospital, Luohe Henan, 462000, P.R.China
| | - Fan Li
- Department of Spine Surgery, Luohe Central Hospital, Luohe Henan, 462000, P.R.China
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Mlyavykh S, Ludwig SC, Kepler CK, Anderson DG. Five-year results of a clinical pilot study utilizing a pedicle-lengthening osteotomy for the treatment of lumbar spinal stenosis. J Neurosurg Spine 2018; 29:241-249. [PMID: 29856305 DOI: 10.3171/2017.11.spine16664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lumbar spinal stenosis (LSS) is a common condition that leads to significant disability, particularly in the elderly. Current therapeutic options have certain drawbacks. This study evaluates the 5-year clinical and radiographic results of a minimally invasive pedicle-lengthening osteotomy (PLO) for symptomatic LSS. METHODS A prospective, single-arm, clinical pilot study was conducted involving 20 patients (mean age 61.7 years) with symptomatic LSS treated by a PLO procedure at 1 or 2 lumbar levels. All patients had symptoms of neurogenic claudication or radiculopathy secondary to LSS, and had not improved after a minimum 6-month course of nonoperative treatment. Eleven patients had a Meyerding grade I degenerative spondylolisthesis in addition to LSS. Clinical outcomes were measured using the Oswestry Disability Index, Zürich Claudication Questionnaire, 12-Item Short Form Health Survey, and a visual analog scale for back and leg pain. Procedural variables, neurological outcomes, adverse events, and radiological imaging (plain radiographs and CT scans) were collected at the 1.5-, 3-, 6-, 9-, 12-, 24-, and 60-month time points. RESULTS The PLOs were performed through percutaneous incisions, with minimal blood loss in all cases. There were no operative complications. Four adverse events occurred during the follow-up period. Statistically significant improvement was observed in each of the outcome instruments and maintained over the 5-year follow-up period. Imaging studies, reviewed by an independent radiologist, showed no evidence of device subsidence, migration, breakage, or heterotopic ossification. Thin-slice CT scans documented healing of the osteotomy site in all patients at the 6-month time point and an increase of 115% in the mean cross-sectional area of the spinal canal. CONCLUSIONS Treatment of patients with symptomatic LSS with a PLO procedure provided substantial enlargement of the area of the spinal canal and favorable clinical results for both disease-specific and non-disease-specific outcome measures at all follow-up time points out to 5 years. Future research is needed to compare this technique to alternative therapies for LSS.
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Affiliation(s)
- Sergey Mlyavykh
- 1Privolzhski Federal Medical Research Center, Nizhniy Novgorod, Russia
| | - Steven C Ludwig
- 2Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Christopher K Kepler
- 3Department of Orthopaedics, Thomas Jefferson University/Rothman Institute, Philadelphia, Pennsylvania
| | - D Greg Anderson
- 3Department of Orthopaedics, Thomas Jefferson University/Rothman Institute, Philadelphia, Pennsylvania
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Iatrogenic Spondylolisthesis Following Open Lumbar Laminectomy: Case Series and Review of the Literature. World Neurosurg 2018; 113:e383-e390. [DOI: 10.1016/j.wneu.2018.02.039] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 02/05/2018] [Accepted: 02/06/2018] [Indexed: 12/11/2022]
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Treatment of Degenerative Lumbar Spondylolisthesis With Fusion or Decompression Alone Results in Similar Rates of Reoperation at 5 Years. Clin Spine Surg 2018; 31:E74-E79. [PMID: 28671881 DOI: 10.1097/bsd.0000000000000564] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Population-based analysis of administrative discharge records from California, Florida, and New York inpatient, ambulatory, and emergency department settings between 2005 and 2011, utilizing Healthcare Cost and Utilization Project data. OBJECTIVE We aimed to compare, and characterize rates of reoperation and readmission among patients with degenerative spondylolisthesis treated with surgical decompression alone versus fusion. SUMMARY OF BACKGROUND DATA Degenerative lumbar spondylolisthesis with stenosis can be treated by decompression with or without fusion. Fusion has traditionally been preferred. We hypothesized that rates of reoperation after decompression alone would be higher than after fusion. MATERIALS AND METHODS We undertook a population-based analysis of administrative discharge records from California, Florida, and New York inpatient, ambulatory, and emergency department settings between 2005 and 2011, with Healthcare Cost and Utilization Project data. We identified all patients who had degenerative spondylolisthesis who were treated with decompression alone or with fusion and compared their rates of reoperation at 1, 3, and 5 years from the index operation. We used descriptive statistics and a hierarchical logistic regression model to generate risk-adjusted odds of all-cause readmissions. RESULTS Our study consisted of 75,024 patients with spondylolisthesis; 6712 (8.95%) of them underwent decompression alone and 68,312 (91.05%) of them underwent fusion. Rates of reoperation were higher for decompression versus fusion at 1 year; 6.87% versus 5.53% (P≤0.001), but at 3 years; 13.86% versus 12.91% (P=0.18) and 5 years; 16.9% versus 17.7% (P=0.398) years rates of reoperation were not statistically different. Patients treated with decompression alone that had a second operation tended to have the operation sooner 512.6 versus 567.4 days (P=0.008). CONCLUSIONS Our study suggests that treatment of degenerative spondylolisthesis with fusion or decompression alone results in similar rates of reoperation at 5 years. This medium term data indicate that decompression alone may be a viable treatment for some patients with degenerative spondylolisthesis.
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Takenaka S, Tateishi K, Hosono N, Mukai Y, Fuji T. Preoperative retrolisthesis as a risk factor of postdecompression lumbar disc herniation. J Neurosurg Spine 2015; 24:592-601. [PMID: 26654340 DOI: 10.3171/2015.6.spine15288] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this study, the authors aimed to identify specific risk factors for postdecompression lumbar disc herniation (PDLDH) in patients who have not undergone discectomy and/or fusion. METHODS Between 2007 and 2012, 493 patients with lumbar spinal stenosis underwent bilateral partial laminectomy without discectomy and/or fusion in a single hospital. Eighteen patients (herniation group [H group]: 15 men, 3 women; mean age 65.1 years) developed acute sciatica as a result of PDLDH within 2 years after surgery. Ninety patients who did not develop postoperative acute sciatica were selected as a control group (C group: 75 men, 15 women; mean age 65.4 years). Patients in the C group were age and sex matched with those in the H group. The patients in the groups were also matched for decompression level, number of decompression levels, and surgery date. The radiographic variables measured included percentage of slippage, intervertebral angle, range of motion, lumbar lordosis, disc height, facet angle, extent of facet removal, facet degeneration, disc degeneration, and vertebral endplate degeneration. The threshold for PDLDH risk factors was evaluated using a continuous numerical variable and receiver operating characteristic curve analysis. The area under the curve was used to determine the diagnostic performance, and values greater than 0.75 were considered to represent good performance. RESULTS Multivariate analysis revealed that preoperative retrolisthesis during extension was the sole significant independent risk factor for PDLDH. The area under the curve for preoperative retrolisthesis during extension was 0.849; the cutoff value was estimated to be a retrolisthesis of 7.2% during extension. CONCLUSIONS The authors observed that bilateral partial laminectomy, performed along with the removal of the posterior support ligament, may not be suitable for lumbar spinal stenosis patients with preoperative retrolisthesis greater than 7.2% during extension.
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Affiliation(s)
- Shota Takenaka
- Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Kosuke Tateishi
- Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Noboru Hosono
- Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Yoshihiro Mukai
- Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Takeshi Fuji
- Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
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Ho YH, Tu YK, Hsiao CK, Chang CH. Outcomes after minimally invasive lumbar decompression: a biomechanical comparison of unilateral and bilateral laminotomies. BMC Musculoskelet Disord 2015; 16:208. [PMID: 26285817 PMCID: PMC4545783 DOI: 10.1186/s12891-015-0659-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 08/03/2015] [Indexed: 11/16/2022] Open
Abstract
Background The unilateral approach for bilateral decompression was developed as an alternative to laminectomy. Unilateral laminotomy has been rated technically considerably more demanding and associated with more perioperative complications than bilateral laminotomy. Several studies have indicated that bilateral laminotomy are associated with a substantial benefit in most outcome parameters and thus constituted a promising treatment alternative. However, no complete kinematic data and relative biomechanical analysis for evaluating spinal instability treated with unilateral and bilateral laminotomy are available. Therefore, the purpose of this study was to compare the stability of various decompression methods. Methods Ten porcine lumbar spines were biomechanically evaluated regarding their strain and range of motion, and the results were compared following unilateral or bilateral laminotomies and laminectomy. The experimental protocol included flexion and extension in the following procedures: intact, unilateral or bilateral laminotomies (L2–L5), and full laminectomy (L2–L5). The spinal segment kinematics was captured using a motion tracking system, and the strain was measured using a strain gauge. Results No significant differences were observed during flexion and extension between the unilateral and bilateral laminotomies, whereas laminectomy yielded statistically significant findings. Regarding strain, significant differences were observed between the laminectomy and other groups. These results suggest that laminotomy entails higher spinal stability than laminectomy, with no significant differences between bilateral and unilateral laminotomies. Conclusions The laminectomy group exhibited more instability, including the index of the range of motion and strain. However, bilateral laminotomy seems to have led to stability similar to that of unilateral laminotomy according to our short-term follow-up. In addition, performing bilateral laminotomies is easier for surgeons than adopting a unilateral approach for bilateral decompression. The results provide recommendations for surgeons regarding final decision making. Future studies conducting long-term evaluation are required.
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Affiliation(s)
- Yi-Hung Ho
- Department of Biomedical Engineering, National Cheng Kung University, No.1, University Road, Tainan, 701, Taiwan.
| | - Yuan-Kun Tu
- Department of Orthopedics, E-DA Hospital, No.1, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung, 824, Taiwan.
| | - Chih-Kun Hsiao
- Department of Medical Research, E-DA Hospital, No.1, Yida Road, Jiaosu Village, Yanchao District, Kaohsiung, 824, Taiwan.
| | - Chih-Han Chang
- Department of Biomedical Engineering, National Cheng Kung University, No.1, University Road, Tainan, 701, Taiwan.
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Lee S, Srikantha U. Spinous Process splitting Laminectomy: Clinical outcome and Radiological analysis of extent of decompression. Int J Spine Surg 2015; 9:20. [PMID: 26114089 DOI: 10.14444/2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Spinous process splitting laminectomy (SPSL) is a useful technique in achieving adequate decompression for lumbar canal stenosis, has the advantage of simultaneously decompressing multiple levels and minimising injury to the paraspinal muscles. Some concern has been expressed over the efficacy of this technique in decompressing lateral recesses. This study was undertaken to assess the clinical outcome of SPSL technique and radiologically assess the extent of decompression. PATIENTS AND METHODS Thirty-nine consecutive patients treated by SPSL for degenerative lumbar spinal stenosis were methodically assessed for demographic data, clinical findings, Pre- and post-op VAS, JOA scores and spinal canal dimensions on imaging. Surgical technique for SPSL is described. RESULTS The mean age of the patients was 66.9 yrs. The mean follow-up was 7.3 months. The mean pre- and post-operative VAS scores were 7.8 and 3.7, respectively. The mean pre- and post-operative JOA scores were 6.3 and 11.2, respectively. The mean JOA recovery rate was 57.3%. 77% of the patients were in the 'good' or 'excellent' McNab's grades at follow-up. Radiologic results were assessed separately at the 118 levels decompressed by the SPSL technique. The ratio increase for the spinal canal dimensions on post-operative images were as follows - Interfacet distance-116.6%; Effective AP distance-67.6%; Right lateral recess depth-165.1%; Right lateral recess angle-145.5%; Left lateral recess depth-149.3%; Left lateral recess angle-133.6%; Cross-sectional spinal canal area-163.8%. There was no worsening of pre-existing degenerative listhesis or scoliosis in any case. CONCLUSION SPSL achieves effective central and lateral recess decompression, at the same time minimising injury to the paraspinal muscles thus reducing post-operative pain and aiding in quicker mobilisation and recovery. It is an effective tool to treat multiple level spinal stenosis, especially in elderly patients who have pre-existing spinal deformities which can precipitate into frank instability after conventional procedures.
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Affiliation(s)
- Seungcheol Lee
- Department of Neurosurgery, Barunsesang Hospital, Seongnam-si, Republic of Korea
| | - Umesh Srikantha
- Department of Neurosurgery, M S Ramaiah Medical Teaching Hospital, Bangalore, India
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Healy AT, Mageswaran P, Lubelski D, Rosenbaum BP, Matheus V, Benzel EC, Mroz TE. Thoracic range of motion, stability, and correlation to imaging-determined degeneration. J Neurosurg Spine 2015; 23:170-7. [PMID: 25978074 DOI: 10.3171/2014.12.spine131112] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The degenerative process of the spinal column results in instability followed by a progressive loss of segmental motion. Segmental degeneration is associated with intervertebral disc and facet changes, which can be quantified. Correlating this degeneration with clinical segmental motion has not been investigated in the thoracic spine. The authors sought to determine if imaging-determined degeneration would correlate with native range of motion (ROM) or the change in ROM after decompressive procedures, potentially guiding clinical decision making in the setting of spine trauma or following decompressive procedures in the thoracic spine. METHODS Multidirectional flexibility tests with image analysis were performed on thoracic cadaveric spines with intact ib cage. Specimens consisted of 19 fresh frozen human cadaveric spines, spanning C-7 to L-1. ROM was obtained for each specimen in axial rotation (AR), flexion-extension (FE), and lateral bending (LB) in the intact state and following laminectomy, unilateral facetectomy, and unilateral costotransversectomy performed at either T4-5 (in 9 specimens) or T8-9 (in 10 specimens). Image grading of segmental degeneration was performed utilizing 3D CT reconstructions. Imaging scores were obtained for disc space degeneration, which quantified osteophytes, narrowing, and endplate sclerosis, all contributing to the Lane disc summary score. Facet degeneration was quantified using the Weishaupt facet summary score, which included the scoring of facet osteophytes, narrowing, hypertrophy, subchondral erosions, and cysts. RESULTS The native ROM of specimens from T-1 to T-12 (n = 19) negatively correlated with age in AR (Pearson's r coefficient = -0.42, p = 0.070) and FE (r = -0.42, p = 0.076). When regional ROM (across 4 adjacent segments) was considered, the presence of disc osteophytes negatively correlated with FE (r = -0.69, p = 0.012), LB (r = -0.82, p = 0.001), and disc narrowing trended toward significance in AR (r = -0.49, p = 0.107). Facet characteristics, scored using multiple variables, showed minimal correlation to native ROM (r range from -0.45 to +0.19); however, facet degeneration scores at the surgical level revealed strong negative correlations with regional thoracic stability following decompressive procedures in AR and LB (Weishaupt facet summary score: r = -0.52 and r = -0.71; p = 0.084 and p = 0.010, respectively). Disc degeneration was not correlated (Lane disc summary score: r = -0.06, p = 0.861). CONCLUSIONS Advanced age was the most important determinant of decreasing native thoracic ROM, whereas imaging characteristics (T1-12) did not correlate with the native ROM of thoracic specimens with intact rib cages. Advanced facet degeneration at the surgical level did correlate to specimen stability following decompressive procedures, and is likely indicative of the terminal stages of segmental degeneration.
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Affiliation(s)
- Andrew T Healy
- Department of Neurological Surgery and.,Head and Neck Research Lab, Cleveland Clinic
| | | | - Daniel Lubelski
- Case Western Reserve University Lerner College of Medicine, Cleveland, Ohio; and
| | | | - Virgilio Matheus
- Department of Neurological Surgery, Southeastern Regional Medical Center, Lumberton, North Carolina
| | - Edward C Benzel
- Department of Neurological Surgery and.,Head and Neck Research Lab, Cleveland Clinic
| | - Thomas E Mroz
- Department of Neurological Surgery and.,Head and Neck Research Lab, Cleveland Clinic
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Hofstetter CP, Hofer AS, Wang MY. Economic impact of minimally invasive lumbar surgery. World J Orthop 2015; 6:190-201. [PMID: 25793159 PMCID: PMC4363801 DOI: 10.5312/wjo.v6.i2.190] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 08/31/2014] [Accepted: 10/16/2014] [Indexed: 02/06/2023] Open
Abstract
Cost effectiveness has been demonstrated for traditional lumbar discectomy, lumbar laminectomy as well as for instrumented and noninstrumented arthrodesis. While emerging evidence suggests that minimally invasive spine surgery reduces morbidity, duration of hospitalization, and accelerates return to activites of daily living, data regarding cost effectiveness of these novel techniques is limited. The current study analyzes all available data on minimally invasive techniques for lumbar discectomy, decompression, short-segment fusion and deformity surgery. In general, minimally invasive spine procedures appear to hold promise in quicker patient recovery times and earlier return to work. Thus, minimally invasive lumbar spine surgery appears to have the potential to be a cost-effective intervention. Moreover, novel less invasive procedures are less destabilizing and may therefore be utilized in certain indications that traditionally required arthrodesis procedures. However, there is a lack of studies analyzing the economic impact of minimally invasive spine surgery. Future studies are necessary to confirm the durability and further define indications for minimally invasive lumbar spine procedures.
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The current testing protocols for biomechanical evaluation of lumbar spinal implants in laboratory setting: a review of the literature. BIOMED RESEARCH INTERNATIONAL 2015; 2015:506181. [PMID: 25785272 PMCID: PMC4345069 DOI: 10.1155/2015/506181] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 01/25/2015] [Indexed: 01/03/2023]
Abstract
In vitro biomechanical investigations have become a routinely employed technique to explore new lumbar instrumentation. One of the most important advantages of such investigations is the low risk present when compared to clinical trials. However, the best use of any experimental data can be made when standard testing protocols are adopted by investigators, thus allowing comparisons among studies. Experimental variables, such as the length of the specimen, operative level, type of loading (e.g., dynamic versus quasistatic), magnitude, and rate of load applied, are among the most common variables controlled during spinal biomechanical testing. Although important efforts have been made to standardize these protocols, high variability can be found in the current literature. The aim of this investigation was to conduct a systematic review of the literature to identify the current trends in the protocols reported for the evaluation of new lumbar spinal implants under laboratory setting.
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Alimi M, Hofstetter CP, Pyo SY, Paulo D, Härtl R. Minimally invasive laminectomy for lumbar spinal stenosis in patients with and without preoperative spondylolisthesis: clinical outcome and reoperation rates. J Neurosurg Spine 2015; 22:339-52. [PMID: 25635635 DOI: 10.3171/2014.11.spine13597] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Surgical decompression is the intervention of choice for lumbar spinal stenosis (LSS) when nonoperative treatment has failed. Standard open laminectomy is an effective procedure, but minimally invasive laminectomy through tubular retractors is an alternative. The aim of this retrospective case series was to evaluate the clinical and radiographic outcomes of this procedure in patients who underwent LSS and to compare outcomes in patients with and without preoperative spondylolisthesis. METHODS Patients with LSS without spondylolisthesis and with stable Grade I spondylolisthesis who had undergone minimally invasive tubular laminectomy between 2004 and 2011 were included in this analysis. Demographic, perioperative, and radiographic data were collected. Clinical outcome was evaluated using the Oswestry Disability Index (ODI) and visual analog scale (VAS) scores, as well as Macnab's criteria. RESULTS Among 110 patients, preoperative spondylolisthesis at the level of spinal stenosis was present in 52.5%. At a mean follow-up of 28.8 months, scoring revealed a median improvement of 16% on the ODI, 2.75 on the VAS back, and 3 on the VAS leg, compared with the preoperative baseline (p < 0.0001). The reoperation rate requiring fusion at the same level was 3.5%. Patients with and without preoperative spondylolisthesis had no significant differences in their clinical outcome or reoperation rate. CONCLUSIONS Minimally invasive laminectomy is an effective procedure for the treatment of LSS. Reoperation rates for instability are lower than those reported after open laminectomy. Functional improvement is similar in patients with and without preoperative spondylolisthesis. This procedure can be an alternative to open laminectomy. Routine fusion may not be indicated in all patients with LSS and spondylolisthesis.
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Affiliation(s)
- Marjan Alimi
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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Zhang ZG, Mei X, Zhang W, Liu P, Gao MF, Yang HL, Luo ZP. Transpedicle osteotomy positioning in pedicle-lengthening laminoplasty. Orthop Surg 2014; 6:313-6. [PMID: 25430715 DOI: 10.1111/os.12144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 10/08/2014] [Indexed: 11/28/2022] Open
Abstract
Pedicle-lengthening laminoplasty is a new minimally invasive technique for surgical treatment of lumbar spinal stenosis. The procedure is performed with the assistance of fluoroscopy and involves creating a pedicle passage, transpedicle osteotomy from inside the pedicle passage and lengthening it by using an implant bilaterally to enlarge the spinal canal and neural foramen. A critical component of the procedure is the precise determination of the osteotomy site on the pedicle. The objective of this study was to examine in vitro whether fluoroscopic positioning could be used to guide the osteotomy and to define the cutting site in the pedicle-lengthening laminoplasty in relation to the posterior vertebral line. It was found that the osteotomy site was from 2.0 to 3.5 mm posterior to the posterior vertebral line. The maximum difference between the measured value and that theoretically simulated on 3-dimensional (3D) computed tomography reconstruction was 0.3 mm. The spinal canal cross-sectional area was significantly enlarged after pedicle-lengthening. Accurate placement of the osteotomy is critical in pedicle-lengthening laminoplasty. Guiding the positioning of the osteotomy based on the posterior vertebral line images provides satisfactory accuracy, suggesting a possible clinical application for our technique; however, further verification in vivo is needed.
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Affiliation(s)
- Zhi-gang Zhang
- Orthopaedic Institute, Department of Orthopaedics, the First Affiliated Hospital of Soochow University, Soochow University, Suzhou, China
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Bisschop A, van Engelen SJPM, Kingma I, Holewijn RM, Stadhouder A, van der Veen AJ, van Dieën JH, van Royen BJ. Single level lumbar laminectomy alters segmental biomechanical behavior without affecting adjacent segments. Clin Biomech (Bristol, Avon) 2014; 29:912-7. [PMID: 25028214 DOI: 10.1016/j.clinbiomech.2014.06.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 05/08/2014] [Accepted: 06/16/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Degenerative lumbar spinal stenosis causes neurological symptoms due to neural compression. Lumbar laminectomy is a commonly used treatment for symptomatic degenerative spinal stenosis. However, it is unknown if and to what extent single level laminectomy affects the range of motion and stiffness of treated and adjacent segments. An increase in range of motion and a decrease in stiffness are possible predictors of post-operative spondylolisthesis or spinal failure. METHODS Twelve cadaveric human lumbar spines were obtained. After preloading, spines were tested in flexion-extension, lateral bending, and axial rotation. Subsequently, single level lumbar laminectomy analogous to clinical practice was performed at level lumbar 2 or 4. Thereafter, load-deformation tests were repeated. The range of motion and stiffness of treated and adjacent segments were calculated before and after laminectomy. Untreated segments were used as control group. Effects of laminectomy on stiffness and range of motion were tested, separately for treated, adjacent and control segments, using repeated measures analysis of variance. FINDINGS Range of motion at the level of laminectomy increased significantly for flexion and extension (7.3%), lateral bending (7.5%), and axial rotation (12.2%). Range of motion of adjacent segments was only significantly affected in lateral bending (-7.7%). Stiffness was not affected by laminectomy. INTERPRETATION The increase in range of motion of 7-12% does not seem to indicate the use of additional instrumentation to stabilize the lumbar spine. If instrumentation is still considered in a patient, its primary focus should be on re-stabilizing only the treated segment level.
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Affiliation(s)
- Arno Bisschop
- Department of Orthopaedic Surgery, Research Institute MOVE, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - Susanne J P M van Engelen
- Research Institute MOVE, Faculty of Human Movement Sciences, VU University, Amsterdam, The Netherlands
| | - Idsart Kingma
- Research Institute MOVE, Faculty of Human Movement Sciences, VU University, Amsterdam, The Netherlands
| | - Roderick M Holewijn
- Department of Orthopaedic Surgery, Research Institute MOVE, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Agnita Stadhouder
- Department of Orthopaedic Surgery, Research Institute MOVE, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Albert J van der Veen
- Department of Physics and Medical Technology, VU University Medical Center, The Netherlands
| | - Jaap H van Dieën
- Research Institute MOVE, Faculty of Human Movement Sciences, VU University, Amsterdam, The Netherlands; Department of Biomedical Engineering, King Abdulaziz University, Saudi Arabia
| | - Barend J van Royen
- Department of Orthopaedic Surgery, Research Institute MOVE, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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Results of cervical recapping laminoplasty: gross anatomical changes, biomechanical evaluation at different time points and degrees of level involvement. PLoS One 2014; 9:e100689. [PMID: 24950103 PMCID: PMC4065099 DOI: 10.1371/journal.pone.0100689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 05/30/2014] [Indexed: 11/22/2022] Open
Abstract
Background Recapping laminoplasty has become the frequently-used approach to the spinal canal when bone decompression of the vertebral canal is not the goal. However, what changes will occur after surgery, and whether recapping laminoplasty can actually reduce the risk of delayed deformities remains unknown. Methodology We designed an animal experiment using a caprine model, and partitioned the animals into in vitro and in vivo surgical groups. We performed recapping laminoplasty on one group and laminectomy on another group. These animals were sacrificed six months after operating, cervical spines removed, biomechanically tested, and these data were compared to determine whether the recapping laminoplasty technique leads to subsequent differences in range of motion. Image data were also obtained before the surgery and when the animals were killed. Besides, we investigated the initial differences in kinetics between recapping laminoplasty and laminectomy. We did this by comparing data obtained from biomechanical testing of in vitro-performed recapping laminoplasty and laminectomy. Finally, we investigated the effect that longitudinal distance has on cervical mechanics. This was determined by performing a two-level recapping laminoplasty, and then extending the laminoplasty to the next level and repeating the mechanical testing at each step. Principal Findings There were three mainly morphological changes at the six months after laminoplasty: volume reduction and bone nonunion of the recapping laminae, irregular fibrosis formation around the facet joints and re-implanted lamina-ligamentous complex. In the biomechanical test, comparing with laminectomy, recapping laminoplasty didn’t show significant differences in the immediate postoperative comparison, while recapping laminoplasty demonstrated significantly decreased motion in flexion/extension six months later. Inclusion of additional levels in the laminotomy procedure didn’t lead to changes in immediate biomechanics. Conclusions Recapping laminoplasty can’t fully restore the posterior structure, but still reduced the risk of delayed cervical instability in a caprine model.
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Hanlon AD, Cook DJ, Yeager MS, Cheng BC. Quantitative Analysis of the Nonlinear Displacement–Load Behavior of the Lumbar Spine. J Biomech Eng 2014; 136:1877321. [DOI: 10.1115/1.4027754] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 05/29/2014] [Indexed: 11/08/2022]
Abstract
There is currently no universal model or fitting method to characterize the visco-elastic behavior of the lumbar spine observed in displacement versus load hysteresis loops. In this study, proposed methods for fitting these loops, along with the metrics obtained, were thoroughly analyzed. A spline fitting technique was shown to provide a consistent approximation of spinal kinetic behavior that can be differentiated and integrated. Using this tool, previously established metrics were analyzed using data from two separate studies evaluating different motion preservation technologies. Many of the metrics, however, provided no significant differences beyond range of motion analysis. Particular attention was paid to how different definitions of the neutral zone capture the high-flexibility region often seen in lumbar hysteresis loops. As a result, the maximum slope was introduced and shown to be well defined. This new parameter offers promise as a descriptive measurement of spinal instability in vitro and may have future implications in clinical diagnosis and treatment of spinal instability. In particular, it could help in assigning treatments to specific stabilizing effects in the lumbar spine.
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Affiliation(s)
- Andrew D. Hanlon
- Department of Neurosurgery, Allegheny General Hospital, 420 East North Avenue, Pittsburgh, PA 15212
| | - Daniel J. Cook
- Department of Neurosurgery, Allegheny General Hospital, 420 East North Avenue, Pittsburgh, PA 15212
| | - Matthew S. Yeager
- Department of Neurosurgery, Allegheny General Hospital, 420 East North Avenue, Pittsburgh, PA 15212
| | - Boyle C. Cheng
- Department of Neurosurgery, Allegheny General Hospital, 420 East North Avenue, Pittsburgh, PA 15212 e-mail:
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Healy AT, Lubelski D, Mageswaran P, Bhowmick DA, Bartsch AJ, Benzel EC, Mroz TE. Biomechanical analysis of the upper thoracic spine after decompressive procedures. Spine J 2014; 14:1010-6. [PMID: 24291701 DOI: 10.1016/j.spinee.2013.11.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 10/02/2013] [Accepted: 11/21/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Decompressive procedures such as laminectomy, facetectomy, and costotransversectomy are routinely performed for various pathologies in the thoracic spine. The thoracic spine is unique, in part, because of the sternocostovertebral articulations that provide additional strength to the region relative to the cervical and lumbar spines. During decompressive surgeries, stability is compromised at a presently unknown point. PURPOSE To evaluate thoracic spinal stability after common surgical decompressive procedures in thoracic spines with intact sternocostovertebral articulations. STUDY DESIGN Biomechanical cadaveric study. METHODS Fresh-frozen human cadaveric spine specimens with intact rib cages, C7-L1 (n=9), were used. An industrial robot tested all spines in axial rotation (AR), lateral bending (LB), and flexion-extension (FE) by applying pure moments (±5 Nm). The specimens were first tested in their intact state and then tested after each of the following sequential surgical decompressive procedures at T4-T5 consisting of laminectomy; unilateral facetectomy; unilateral costotransversectomy, and subsequently instrumented fusion from T3-T7. RESULTS We found that in all three planes of motion, the sequential decompressive procedures caused no statistically significant change in motion between T3-T7 or T1-T12 when compared with intact. In comparing between intact and instrumented specimens, our study found that instrumentation reduced global range of motion (ROM) between T1-T12 by 16.3% (p=.001), 12% (p=.002), and 18.4% (p=.0004) for AR, FE, and LB, respectively. Age showed a negative correlation with motion in FE (r = -0.78, p=.01) and AR (r=-0.7, p=.04). CONCLUSIONS Thoracic spine stability was not significantly affected by sequential decompressive procedures in thoracic segments at the level of the true ribs in all three planes of motion in intact thoracic specimens. Age appeared to negatively correlate with ROM of the specimen. Our study suggests that thoracic spinal stability is maintained immediately after unilateral decompression at the level of the true ribs. These preliminary observations, however, do not depict the long-term sequelae of such procedures and warrant further investigation.
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Affiliation(s)
- Andrew T Healy
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, S4, Cleveland, OH 44195, USA.
| | - Daniel Lubelski
- Cleveland Clinic Lerner College of Medicine, 9500 Euclid Ave, NA21, Cleveland, OH 44195, USA
| | - Prasath Mageswaran
- Head, Neck & Spine Research Laboratory, 1730 W. 25(th) St, Lutheran Hospital, 2C, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Deb A Bhowmick
- Department of Neurosurgery, University of North Carolina, 170 Manning Dr, Campus Box 7060, Chapel Hill, NC 27599, USA
| | - Adam J Bartsch
- Head, Neck & Spine Research Laboratory, 1730 W. 25(th) St, Lutheran Hospital, 2C, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Edward C Benzel
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, S4, Cleveland, OH 44195, USA
| | - Thomas E Mroz
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, S4, Cleveland, OH 44195, USA
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Smith ZA, Vastardis GA, Carandang G, Havey RM, Hannon S, Dahdaleh N, Voronov LI, Fessler RG, Patwardhan AG. Biomechanical effects of a unilateral approach to minimally invasive lumbar decompression. PLoS One 2014; 9:e92611. [PMID: 24658010 PMCID: PMC3962436 DOI: 10.1371/journal.pone.0092611] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 02/23/2014] [Indexed: 02/07/2023] Open
Abstract
Minimally invasive (MI) lumbar decompression became a common approach to treat lumbar stenosis. This approach may potentially mitigate postoperative increases in segmental motion. The goal of this study was to evaluate modifications to segmental motion in the lumbar spine following a MI unilateral approach as compared to traditional facet-sparing and non-facet sparing decompressions. Six human lumbar cadaveric specimens were used. Each specimen was tested in flexion-extension 0 N and 400 N of follower preload), axial rotation, and lateral bending. Each testing condition was evaluated following three separate interventions at L4–L5: 1) Minimally invasive decompression, 2) Facet-sparing, bilateral decompression, and 3) Bilateral decompression with a wide facetectomy. Range of motion following each testing condition was compared to intact specimens. Both MI and traditional decompression procedures create significant increases in ROM in all modes of loading. However, when compared to the MI approach, traditional decompression produces significantly larger increase in ROM in flexion-extension (p<0.005) and axial rotation (p<0.05). It additionally creates increased ROM with lateral bending on the approach side (p<0.05). Lateral bending on the non-approach side is not significantly changed. Lastly, wide medial facet removal (40% to 50%) causes significant hypermobility, especially in axial rotation. While both MI and traditional lumbar decompressions may increase post-operative ROM in all conditions, a MI approach causes significantly smaller increase in ROM. With an MI approach, increased movement with lateral bending is only toward the approach side. Further, non-facet sparing decompression is further destabilizing in all loading modes.
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Affiliation(s)
- Zachary A. Smith
- Northwestern Feinberg School of Medicine, Department of Neurological Surgery, Northwestern University, Chicago, Illinois, United States of America
| | - Georgios A. Vastardis
- Loyola University Stritch School of Medicine, Department of Orthopaedic Surgery, Maywood, Illinois, United States of America
- Edward Hines Jr. VA Hospital, Hines, Illinois, United States of America
| | - Gerard Carandang
- Loyola University Stritch School of Medicine, Department of Orthopaedic Surgery, Maywood, Illinois, United States of America
- Edward Hines Jr. VA Hospital, Hines, Illinois, United States of America
| | - Robert M. Havey
- Loyola University Stritch School of Medicine, Department of Orthopaedic Surgery, Maywood, Illinois, United States of America
- Edward Hines Jr. VA Hospital, Hines, Illinois, United States of America
| | - Sean Hannon
- Loyola University Stritch School of Medicine, Department of Orthopaedic Surgery, Maywood, Illinois, United States of America
- Edward Hines Jr. VA Hospital, Hines, Illinois, United States of America
| | - Nader Dahdaleh
- Northwestern Feinberg School of Medicine, Department of Neurological Surgery, Northwestern University, Chicago, Illinois, United States of America
| | - Leonard I. Voronov
- Loyola University Stritch School of Medicine, Department of Orthopaedic Surgery, Maywood, Illinois, United States of America
- Edward Hines Jr. VA Hospital, Hines, Illinois, United States of America
| | - Richard G. Fessler
- Northwestern Feinberg School of Medicine, Department of Neurological Surgery, Northwestern University, Chicago, Illinois, United States of America
| | - Avinash G. Patwardhan
- Loyola University Stritch School of Medicine, Department of Orthopaedic Surgery, Maywood, Illinois, United States of America
- Edward Hines Jr. VA Hospital, Hines, Illinois, United States of America
- * E-mail:
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Compressive preload reduces segmental flexion instability after progressive destabilization of the lumbar spine. Spine (Phila Pa 1976) 2014; 39:E74-81. [PMID: 24153162 DOI: 10.1097/brs.0000000000000093] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Biomechanical human cadaveric study. OBJECTIVE We hypothesized that increasing compressive preload will reduce the segmental instability after nucleotomy, posterior ligament resection, and decompressive surgery. SUMMARY OF BACKGROUND DATA The human spine experiences significant compressive preloads in vivo due to spinal musculature and gravity. Although the effect of destabilization procedures on spinal motion has been studied, the effect of compressive preload on the motion response of destabilized, multisegment lumbar spines has not been reported. METHODS Eight human cadaveric spines (L1-sacrum, 51.4 ± 14.1 yr) were tested intact, after L4-L5 nucleotomy, after interspinous and supraspinous ligaments transection, and after midline decompression (bilateral laminotomy, partial medial facetectomy, and foraminotomy). Specimens were loaded in flexion (8 Nm) and extension (6 Nm) under 0-N, 200-N, and 400-N compressive follower preload. L4-L5 range of motion (ROM) and flexion stiffness in the high-flexibility zone were analyzed using repeated-measures analysis of variance and multiple comparisons with the Bonferroni correction. RESULTS With a fixed set of loading conditions, a progressive increase in segmental ROM along with expansion of the high-flexibility zone (decrease of flexion stiffness) was noted with serial destabilizations. Application of increasing compressive preload did not substantially change segmental ROM, but did significantly increase the segmental stiffness in the high-flexibility zone. In the most destabilized condition, 400-N preload did not return the segmental stiffness to intact levels. CONCLUSION Anatomical alterations representing degenerative and iatrogenic instabilities are associated with significant increases in segmental ROM and decreased segmental stiffness. Although application of compressive preload, mimicking the effect of increased axial muscular activity, significantly increased the segmental stiffness, it was not restored to intact levels; thereby suggesting that core strengthening alone may not compensate for the loss of structural stability associated with midline surgical decompression. This suggests that there may be a role for surgical implants or interventions that specifically increase flexion stiffness and limit flexion ROM to counteract the iatrogenic instability resulting from surgical decompression. LEVEL OF EVIDENCE N/A.
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Baker AA, Glassman SD, Carreon LY. Outcomes in patients with minimal back pain undergoing prophylactic lumbar fusion for iatrogenic instability. Orthopedics 2013; 36:e1534-7. [PMID: 24579226 DOI: 10.3928/01477447-20131120-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
For most patients undergoing lumbar fusion, back pain is a substantial part of their preoperative symptomatology. Occasionally, there are patients with minimal back pain in whom the extent of decompression required to treat leg symptoms requires a concomitant fusion to prevent postoperative instability. Although these patients may obtain relief of their leg pain, an additional concern is whether they will develop increased back pain after fusion. This study’s primary cohort comprised 1144 patients with complete preoperative and 2-year postoperative data including the Oswestry Disability Index (ODI), Short Form 36 (SF-36), and numeric rating scales (NRS) for back and leg pain. Thirty-nine patients with a preoperative back pain score of 3 or less were identified. Propensity scoring was used to match these patients to patients with moderate back pain (NRS 4-6) and severe back pain (NRS 7-10) based on demographics, baseline health-related quality of life, and surgical characteristics, resulting in 35 patients in each group. Paired t tests were used to determine within-group differences, and analysis of variance was used to determine between-group differences. A statistically significant improvement occurred in ODI, SF-36 Physical Component Summary, and NRS leg pain scores from preoperatively to 2 years postoperatively (P<.0001) within all groups; and a statistically significant improvement occurred in back pain scores in the moderate and severe back pain groups. No statistically significant change occurred in back pain from preoperatively to 2 years postoperatively (P=.528) in the minimal back pain group. Patients undergoing lumbar fusion for predominant leg pain with minimal back pain had acceptable outcomes, with no increase in back pain postoperatively.
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Mlyavykh S, Ludwig SC, Mobasser JP, Kepler CK, Anderson DG. Twelve-month results of a clinical pilot study utilizing pedicle-lengthening osteotomy for the treatment of lumbar spinal stenosis. J Neurosurg Spine 2013; 18:347-55. [DOI: 10.3171/2012.11.spine12402] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Lumbar spinal stenosis (LSS) is a common condition that leads to significant disability, particularly in the elderly. Current therapeutic modalities for LSS have certain drawbacks when applied to this patient population. The object of this study was to define the 12-month postoperative outcomes and complications of pedicle-lengthening osteotomies for symptomatic LSS.
Methods
A prospective, single-treatment clinical pilot study was conducted. A cohort of 19 patients (mean age 60.9 years) with symptomatic LSS was treated by pedicle-lengthening osteotomy procedures at 1 or 2 levels. All patients had symptoms of neurogenic claudication or radiculopathy secondary to LSS and had not improved after a minimum 6-month course of nonoperative treatment. Eleven patients had a Meyerding Grade I degenerative spondylolisthesis in addition to LSS. Clinical outcomes were measured using the Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), 12-Item Short-Form Health Survey (SF-12), and a visual analog scale (VAS). Procedural variables, neurological outcomes, adverse events, and radiological imaging (plain radiographs and CT scans) were collected at the 1.5-, 3-, 6-, 9-, and 12-month time points.
Results
The pedicle-lengthening osteotomies were performed through percutaneous approaches with minimal blood loss in all cases. There were no operative complications. Four adverse events occurred during the follow-up period. Clinically, significant improvement was observed in the mean values of each of the outcome scales (comparing preoperative and 12-month values): ODI scores improved from 52.3 to 28.1 (p < 0.0001); the ZCQ physical function domain improved from 2.7 to 1.8 (p = 0.0021); the SF-12 physical component scale improved from 27.0 to 37.9 (p = 0.0024); and the VAS score for leg pain while standing improved from 7.2 to 2.7 (p < 0.0001). Imaging studies, reviewed by an independent radiologist, showed no evidence of device subsidence, migration, breakage, or heterotopic ossification. Thin-slice CT documented healing of the osteotomy site in all patients at the 6-month time point and an increase in the mean cross-sectional area of the spinal canal of 115%.
Conclusions
Treatment of patients with symptomatic LSS with a pedicle-lengthening osteotomy procedure provided substantial enlargement of the area of the spinal canal and favorable clinical results for both disease-specific and non–disease-specific outcome measures at the 12-month time point. Future studies are needed to compare this technique to alternative therapies for lumbar stenosis.
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Affiliation(s)
- Sergey Mlyavykh
- 1Nizhny Novgorod Research Institute of Traumatology and Orthopaedics, Nizhny Novgorod, Russia
| | - Steven C. Ludwig
- 2Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Christopher K. Kepler
- 4Department of Orthopaedic Surgery, Thomas Jefferson University/Rothman Institute, Philadelphia, Pennsylvania
| | - D. Greg Anderson
- 4Department of Orthopaedic Surgery, Thomas Jefferson University/Rothman Institute, Philadelphia, Pennsylvania
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Abstract
Minimally invasive spine surgery (MISS) techniques were developed to address morbidities associated with open spinal surgery approaches. MISS was initially applied for indications such as the microendoscopic decompression of stenosis (MEDS)-an operation that has become widely implemented in modern spine surgery practice. Minimally invasive surgery for MEDS is an excellent example of how an MISS technique has improved outcomes compared with the use of traditional open surgical procedures. In parallel with reports of surgeon experience, accumulating clinical evidence suggests that MISS is favoured over open surgery, and one could argue that the role of MISS techniques will continue to expand. As the field of minimally invasive surgery has developed, MISS has been implemented for the treatment of increasingly difficult and complex pathologies, including trauma, spinal malignancies and spinal deformity in adults. In this Review, we present the accumulating evidence in support of minimally invasive techniques for established MISS indications, such as lumbar stenosis, and discuss the need for additional level I and level II data to demonstrate the benefit of MISS over traditional open surgery. The expanding utility of MISS techniques to address an increasingly broad range of spinal pathologies is also highlighted.
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Pradhan BB, Turner AWL, Zatushevsky MA, Cornwall GB, Rajaee SS, Bae HW. Biomechanical analysis in a human cadaveric model of spinous process fixation with an interlaminar allograft spacer for lumbar spinal stenosis: Laboratory investigation. J Neurosurg Spine 2012; 16:585-93. [PMID: 22519928 DOI: 10.3171/2012.3.spine11631] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECT Traditional posterior pedicle screw fixation is well established as the standard for spinal stabilization following posterior or posterolateral lumbar fusion. In patients with lumbar spinal stenosis requiring segmental posterior instrumented fusion and decompression, interlaminar lumbar instrumented fusion (ILIF) is a potentially less invasive alternative with reduced morbidity and includes direct decompression assisted by an interlaminar allograft spacer stabilized by a spinous process plate. To date, there has been no biomechanical study on this technique. In the present study the biomechanical properties of the ILIF construct were evaluated using an in vitro cadaveric biomechanical analysis, and the results are presented in comparison with other posterior fixation techniques. METHODS Eight L1-5 cadaveric specimens were subjected to nondestructive multidirectional testing. After testing the intact spine, the following conditions were evaluated at L3-4: bilateral pedicle screws, bilateral laminotomy, ILIF, partial laminectomy, partial laminectomy plus unilateral pedicle screws, and partial laminectomy plus bilateral screws. Intervertebral motions were measured at the index and adjacent levels. RESULTS Bilateral pedicle screws without any destabilization provided the most rigid construct. In flexion and extension, ILIF resulted in significantly less motion than the intact spine (p < 0.05) and no significant difference from the laminectomy with bilateral pedicle screws (p = 0.76). In lateral bending, there was no statistical difference between ILIF and laminectomy with unilateral pedicle screws (p = 0.11); however, the bilateral screw constructs were more rigid (p < 0.05). Under axial rotation, ILIF was not statistically different from laminectomy with unilateral or bilateral pedicle screws or from the intact spine (p > 0.05). Intervertebral motions adjacent to ILIF were typically lower than those adjacent to laminectomy with bilateral pedicle screws. CONCLUSIONS Stability of the ILIF construct was not statistically different from bilateral pedicle screw fixation following laminectomy in the flexion and extension and axial rotation directions, while adjacent segment motions were decreased. The ILIF construct may allow surgeons to perform a minimally invasive, single-approach posterior decompression and instrumented fusion without the added morbidity of traditional pedicle screw fixation and posterolateral fusion.
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Schroeder GD, Murray MR, Hsu WK. A Review of Dynamic Stabilization in the Lumbar Spine. ACTA ACUST UNITED AC 2011. [DOI: 10.1053/j.oto.2011.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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