Clinical and Radiological Outcomes of Segmental Spinal Fusion in Transforaminal Lumbar Interbody Fusion with Spinous Process Tricortical Autograft

STUDY DESIGN: A retrospective study. PURPOSE: To investigate clinical and radiological outcomes when using spinous process as a tricortical autograft for segmental spinal fusion in transforaminal lumbar interbody fusion (TLIF). OVERVIEW OF LITERATURE: Interbody spinal fusion is one of the important procedures in spinal surgery. Many types of autografts are harvested at the expense of complications. Clinical and radiographic results of patients who underwent TLIF with intraoperative harvested spinous process autograft in Prasat Neurological Institue, Bangkok, Thailand, were assessed as new technical innovation. METHODS: Between October 2005 to July 2009, 30 cases of patients who underwent TLIF with spinous process tricortical autograft were included. Clinical evaluations were assessed by visual analog scales (VAS) and Prolo functional and economic scores at the preoperation and postoperation and at 2 years postoperation. Static and dynamic plain radiograph of lumbar spine were reviewed for achievement of fusion. RESULTS: Initial successful fusion time in lumbar interbody fusion with spinous process tricortical autograft was 4.72 months (range, 3.8-6.1 months) postoperation and 100% fusion rate was reported at 2 years. Our initial successful fusion time in lumbar interbody fusion was compared to the other types of grafts in previous literatures. CONCLUSIONS: The use of intraoperative harvested spinous process tricortical autograft has overcome many disadvantages of harvesting autograft with better initial successful fusion time (4.72 months). VAS and Prolo scores showed some improvement in the outcomes between the preoperative and postoperative periods.

Unilateral vertebral plate decompression, interbody fusion and pedicle screw fixation in treatment of lumbar disc berniation / 第二军医大学学报

Objective:To explore the application and efficiency of unilateral vertebral plate decompresaion,interbody fusion and pedicle screw fixation in treatment of lumbar disc herniation. Methods1From Feb. 2006 to Feb. 2008,24 patients underwent unilateral vertebral plate decompression,interbody fusion and pedicle screw fixation. The patients were followed up for one year and the following data were recorded:operation time,estimated blood loss,duration of hospital-stay,short-term and medium-term clinical outcome. Results1 All patients had their low back pain and/or lower extremity radicular pain improved during the one year follow-up. The last follow-up showed that the numbers of patients with Oswestry Disability Index( ODI) P0-PS were 5 , 11, 6, 2,0, and 0, respectively. The clinical outcomes determined by modified JOA criteria showed that 18 patients had excellent outcomes,4 had good outcomes,and 2 had fair outcomea,with the excellent and good outcomes occupying 91. 67%. Conclusion1 The unilateral fixation can be used in patients with lumbar disc herniations who need lumbar spinal fusion. The medium-term outcomes is satisfactory.

The Effect of Vertebral Wedge Angle to the Change of Kyphotic Angle by the Posterior Instrumentation Method in Thoracolumbar Spine Fracture / 대한척추외과학회지

STUDY DESIGN: Retrospective study OBJECTIVES: To examine the effect of transpedicular screw fixation on fractured vertebrae about the vertebral wedge angle (VWA) after posterior instrumentation of the thoracolumbar fracture, determine the effect of reduced VWA on the change in the Kyphotic angle (KA), and minimize loss of reduction of KA. SUMMARY OF THE LITERATURE REVIEW: Maintenance of the KA of a thoracolumbar fracture after surgery is important for the radiologic and functional outcome. MATERIALS AND METHODS: Forty patients, who had undergone posterior instrumentation in a thoracolumbar fracture between February 2006 and February 2008 and followed-up for more than one year, were enrolled in this study. The patients were divided into two groups according to transpedicular screw fixation (Group A) or not (Group B) including fractured vertebrae. The evaluation was performed by measuring the changes in the KA and VWA taken after the injury, immediate after surgery and 1 year after surgery. RESULTS: There was correlation between groups A (transpedicular screw fixation on fractured vertebrae) and B (no transpedicular screw fixation on the fractured vertebrae) regarding the correction of the VWA and the loss of correction KA, (p<0.05). CONCLUSIONS: Reduction of the VWA is an important factor for preventing reduction loss of the KA, and transpedicular screw fixation including fractured vertebrae would help reduce the VWA. Therefore, the operator must pay attention to the increase in VWA to maintain the KA through short segment transpedicular screw fixation including fractured vertebrae.

Metal Failure in patients with Short-segmental Pedicle Screw Fixation and Fusion for Degenerative Lumbar Disease: Comparison Monoaxial with Polyaxial Screw / 대한척추외과학회지

STUDY DESIGN: Retrospective study OBJECTIVE: To evaluate the factors affecting metal failure and screw loosening of short-segmental (1- or 2-segmental) monoaxial or polyaxial screw fixation for degenerative lumbar disease. SUMMARY OF LITERATURE REVIEW: There was a report on metal failure and screw loosening in short-segmental monoaxial and polyaxial screw fixation in degenerative lumbar disease. MATERIALS AND METHODS: This study examined 227 cases who underwent short-segmental transpedicular screw fixation and vertebral fusion for a degenerative lumbar. RESULTS: Metal failure of transpedicular screws was detected in 6 cases, 3 each in groups A and B. Screw loosening occurred in 16 and 43 cases in group A and B, respectively. Both groups had a similar incidence of spinal stenosis with instability and spondylolisthesis. The failure rate and screw loosening according to the fusion level was also similar. The failure and screw loosening rates was higher in the cases who did not undergo PLIF than in the cases who underwent PLIF but the difference was not statistically significant. CONCLUSION: The metal failure and screw loosening rates after transpedicular screw fixation and spinal fusion procedures for degenerative lumbar diseases using monoaxial screws and polyaxial screws were similar.

Operative Treatment for Hangman Fracture of the Axis: Review of Fixation Methods and Indications / 대한척추외과학회지

OBJECTIVES: To evaluate the surgical indications and to compare the results of the anterior plate fixation and transpedicular fixation in cases of traumatic spondylolisthesis of the axis. MATERIALS AND METHODS: From 1987 to 2001, eighteen of 26 cases of traumatic spondylolisthesis of the axis were treated by anterior plate fixation and 8 of 26 by transpedicular screw fixation. Two of 8 cases received unilateral screw fixation and 6bilateral fixation. Two cases of the transpedicular screw fixation group were treated by additional posterior plate fixation. Oper-ativeindication was an unstable fracture, namely, with over 3.5 mm of anterior displacement, over 10 degrees of angulation, i.e., Levine types II, IIA, III, and IA. Postoperatively, Philadelphia orthosis or a soft collar was applied for 6 to 8 weeks. RESULTS: All cases achieved bone union. One case of neck pain, three cases of neck motion limitation and three cases of a kyphotic deformity exceeding 10degrees were observed in the posterior transpedicular screw fixation group. In terms of surgical complications, two cases of transient dysphagia were observed in the anterior plate fixation group and two cases of screw malposition in the transpedicular screw fixation group. The transpedicular screw fixation technique has some associated problems, such as a large operative wound scar, a large bleeding volume, and technical difficulty. CONCLUSION: Both the anterior plate fixation and transpedicular screw fixation methods are useful treatment methods for Levine type II, IIA and III hangman fracture for early bone union and early rehabilitation. The anterior plate fixation technique is easi-er and has fewer complications than posterior transpedicular screw fixation, therefore, the ranspedicular screw fixation method should be confined to the management of type IA fracture with rotational displacement.

Evoked EMG Monitoring During Transpedicular Fixation of Lumbosacral Spine

OBJECTIVE: The purpose of this study is to evaluate the searching stimulus intensity at each pedicle and to identify the most vulnerable roots in transpedicular screw fixation of lumbosacral spine. METHOD: Thirty-two patients with unstable lumbosacral vertebra were treated with intrapedicular screw fixation. Small holes were made by an air drill on the pedicle from L2 to S1 for screw fixation. Constant current stimulation pulses(0.2 msec duration) were delivered through a ball-tipped nasopharyngeal probe used to palpate the walls of each pedicle, and observation was made of electromyogram(EMG) evoked lower extremity muscles. The probes were placed in each pedicular wall manually, and evaluated for searching stimulus intensity, the current necessary to evoked EMG. RESULTS: The cases that the searching stimulus intensity was above 5 mA were 99 cases(97%), above 10 mA were 61 cases(59.8%) and below 5 mA were 3 cases(2.9%). The vastus medialis muscle is most sensitive in L2(100%) and L3(78.9%), tibialis anterior is in L4(81.8%), Peroneus longus is in L5(50.5%) and gastrocnemius is in S1(87.5%). CONCLUSION: We can regard the searching stimulus intensity as 5 mA and the root located at Infero-medial side of pedicle is most vulnerable in transpedicular screw fixation. Furthermore, stimulus-evoked EMG monitoring during transpedicular spine instrumentation is helpful to avoid neural tissue injury.

Results of Transpedicular Screw Fixation in Spondylolisthesis of the Lumbar Spine

The auther studied 54 lumbar spondylolisthesis patients diagnosed and treated with transpedicular screw fixation and bony fusion at our Hosptial between January 1990 and December 1994, and analysed the outcome. The results may be summarized as follows: 1) Of the 54 cases, 17 were degenerative spondylolisthesis and 37 were spondylolytic spondylolisthesis. Occurrence peaked during the fifth and sixth decades. 2) Posterolateral fusion(P.L.F) was performed in 37 cases and posterior lumbar interbody fusion(P.L.I.F) in eight ; P.L.F and P.L.I.F in combination was performed in nine cases. The mean follow-up period was 25 months. 3) In no patients was significant neurologic injury or functional root loss seen. Complications included two instrument failures and one wound infection. 4) Radiologic and clinical outcome was better in degenerative than in spondylolitic spondylolisthesis. 5) The radiologic and clinical outcome of bony fusion types P.L.F and P.L.I.F was the same. 6) The surgical result as evaluated by Mc.Nab's criteria was satisfactory in 81% of patients.

Evaluation of Clinical Result of Transpedicular Screw Fixation and Modified Posterior Fusion for Lumbar Spondylolisthesis

During the past five years(1990. 7-1995. 6,) eighteen patients with symptomatic lumbar spondylolisthesis whose neurogenic intermittent claudication appeared within fifteen minutes of walking, but otherwise suffered from no significant disc herniation at the involved level, underwent operation. The lumbar spine was stabilized by transpedicular screw fixation and modified posterior fusion instead of posterior lumbar interbody fusion(PLIF). There were three males and fifteen females and the average age was fourty-seven years(range, thirty-six to sixty-four years). After an average follow-up period of thirty-one months(range, fifteen to fifty-two months), the result were excellent in eight, good in seven, moderate in two, and poor in one patients. The satisfactory result of 83.3 percent of the patients suggested that the modified posterior fusion, instead of posterior lumbar interbody fusion, in which the spinous process, the lamina, the facet joint, and only the base of the transverse process were included, after transpedicular screw fixation in lumbar spondylolis thetic patients would be enough when there is no significant disc herniation at the involved level.

Surgical Experience of transpediculr Screw Fixation of the Spine

Vertebral transpedicular screws provide secure attachment for posterior spinal fixation device, the authors had experienced 29 cases of transpedicular screw fixation to obtain fixations of the thorcolumbar and lumbar spine instability, the patients were operated between February, 1992, and May, 1995. Spinal Fusion was attempted at one to four levels of thoracic and lumbar spine. Follow-up period was from 6 to 33 months, averaging 16 months. The result was summerized as follows: 1) Of the 29 cases, 20 were spondylolisthesis and 9 were fracture and dislocation. 10 patients(34.5%) were 30 years old, and 20 cases(69%) were female. Mean age was 42 years. 2) The symptom included low back pain, sciatica and intemittant claudificaton in the order of incidence. 3) The sites of spondylolisthesis were L4-5 in 12 cases(60%) and L5-S1 in 8 cases(40%). The average degree of slippage in spondylolisthesis was Meyerding's grade I(85%). The sites of fracture were T12 in 5 cases(55.6%), L1 in 2 cases(22.2%), L2 with L3 in 1case(11.1%) and L1 in 1 case(11.1%). 4) There was no patient with significant neurologic injury or functional root loss. A screw malposition was observed in one case. 5) The results of operations were considered exellent in 16 cases(55%), good in 10 cases(35%) and fair in 3 cases(10%), and satisfactory bony fusion was obtained.

Posterior Lumbar Interbody Fusion with Pedicle Screw Fixation for Lumbar Spondylolisthesis

The theoretical advantages of spondlylolisthesis reduction-fixation are substantial, but some questions such as excessive risk and morbidity relative to in situ fusion remain unresolved yet. This study included 10 consecutive patients(2 male, 8 female) who underwent posterior lumbar interbody fusion(PLIF) with transpedicular instrumentation(AKITA pedicular screw system) over the past six menths from July to December 1993. All patients were isthmic type, adult(between 30 and 57) and between grades I and II. Claudication was the most common symptom. All patients were operated upon by one surgeon(C.K.P.) and follow-up was conducted through patient interviews and examinations, both clinically and rediologically. The patients were followed postoperatively from 6 to 12 months. There were no neurologic complication related to the procedures. The clinical outcomes assessed more than 6 months postoperatively were as follows:improvement, 9/10;stationary 1/10. Radiologically, the mean reduction rate of slippage(preoperative percentage slip-postoperrative one/preoperative one x100) was 4.3% and all patients developed solid fusion. In conclusion, patients who underwent PLIF supplemented with transpedicular fixation had good overall clinical and radiological outcomes without significant neurological complications related to PLIF or screw placement.

Loss of the Sagittal angle in the Instrumented Segments after Pedicular Screw Fixation of the Degenerative Lumbar Diseases / 대한정형외과학회잡지

Vertebral stabilization using transpedicular screw fixation device is widely used in the surgical treatment of degenerative lumber diseases such as spinal stenosis, pseudospondylolisthesis, and spinal instability. The use of transpedicular screw fixation devices provides substantial advantages with regard to an increase of the rate of solid arthrodesis, early rehabilitation, short segment spinal fusion, and restoration of sagittal lumbar lordosis. The authors analyzed 11 patients showing definite postoperative loss of the lumbar sagittal lordosis in a total of 110 surgical cases of degenerative lumbar diseases who underwent segmental spinal fusion using transpedicular screws from January 1981 to December 1993. The purpose of this study was to analyze the causes of loss of lumbar sagittal lordosis in the instrumented segments and to present some precautions in transpedicular screw fixation for surgical patients with degenerative lumbar spines to maintain corrected lumbar sagittal lordosis. The results from this study were as follows: 1. By standard Cobb lateral measurements, eleven cases in a total of 110 patients showed definite loss of lumbar sagittal lordosis more than 4 degrees. 2. The period reflecting loss of lordosis was roughly within postoperative four months which were critical fusion time of the grafted bone mass, which lasted an average of 4.8 months in this study. 3. The implants led to loss of lordosis consisted of 6 cases in 53 Diapasons, 4 cases in 32 Wiltses, and a case in 15 Steffee plate systems. Diapason & Steffee plate systems were classified as a rigid type and Wiltse system as a flexible one. 4. The causes of postoperative loss of lordosis were recognized as 2 cases of screw toggling, 5 cases of screw-rod locking failure and 4 cases of rod bending. 5. The group resulted in more loss of lordosis in degrees was related to significant change between preoperative and postoperative lordosis, distraction of disc space during operation, extensive discectomy, and reduction of degenerative spondylolisthesis which were the cases of the anterior column deficiency.

Surgical Experience of Transpedicular Screw Fixation of the Lumbar Spine

Transpedicular screw fixation of the lumbar spine has evolved rapidly and become one of the reliable methods to application. We treated 42 cases of lumbar spine disease using above method from October, 1987, to Febuary, 1993. The disease entities were spondylolisthesis 24 cases(58%), spondylolysis 14 cases(33%), fracture and dislocation 3 cases(7%), postsurgical instability 1 case(2%). The most frequent clinical symptom and sign was low back pain with radiating pain accompanying limitation of straight leg raising, which clinical outcome was excellent with wide laminectomy. The transpedicular screw fixation allow adequate neural decompression, short segment fixation and prevention of motion limitation of lumbar spine. But one of the important complication driven with this method was root injury which must be prevented by surgen's throught knowledge to pedicular anatomy and meticulous operative technique. The instrument failure is also the troublesome problem. The appropriate bone fusion will be the acceptable strategy to overcome the eventual possibility of instument failure.

Transpedicular Zielke Instrumentation of Spondylolisthesis after Anatomical Reduction / 대한정형외과학회잡지

The authors report the experience of twenty patients of transpedicular Zielke instrumentation after anatomical reduction of the spondylolisthesis. Anstomical reduction was done with the aid of temporary application of Harrington distraction rod, and the reduced segment was fixed with transpedicular Zielke instrumentation. And, anterior interbody fusion was supplemented in a single stage operation. Follow up period was between 13 to 25 months after operation with the average of 19 months. 1. The age of the patients was 38 years in average ranging from 11 to 61 years. 2. Types of the spondylolisthesis were spondylolytic type in 11 cases, degenerative type in 6 cases, dysplastic type in 1 case and pathologic type in 2 cases. 3. The level of the lesion were L5-Sl in 12 cases, L4-5 in 7 cases and L3-4 in 1 case. 4. Pre-operative clinical feature included low back pain in 95%, radiating pain in 65%, and neurological claudication in 45%. 5. The average percentage of slippage was changed from 24% preoperatively to 6% postoperatively and to 8% at the final follow up. The initial correction rate was 75% and the amount of correction loss during the follow up period was 11% in average. 6. Slip angle was changed from 3°preoperatively to −3°poetoperatively and to 0°at the end of follow up. In the 12 cases with local kyphosis, average slip angle of 14°preoperatively was improved to 2°postoperatively, and to 7°at the end of follow up. 7. Bony fusion was obtained in 19 cases within 4 to 6 months. 8. There were 2 cases of metal failure with considerable loss of reduction ; one patient with pathologic spondylolisthesie due to active tuberculous spondylitis required re-operation and another patient showed fusion eventually in the redisplaced position. Other complication included 1 transient dysuria, 1 ileus and 2 meralgia paresthetics. 9. Clinical symptoms were improved in 95%. Follow up result of the operation according to Gill's criteria were excellent 65%, good 25%, fair 5%, and poor 5%.