The Safety and Efficacy of Cadaveric Allografts and Titanium Cage as a Fusion Substitutes in Pyogenic Osteomyelitis

OBJECTIVE: The safety and efficacy of various fusion substitutes in pyogenic osteomyelitis has not been investigated. We evaluated and compared the cadaveric allograft and titanium cages used to reconstruct, maintain alignment and achieve fusion in the management of pyogenic spinal infection. METHODS: There were 33 patients with pyogenic osteomyelitis underwent fusion in this study. Fifteen of the 33 patients were operated on by fusion with allografts (cadaveric patella bones) and 18 of those were operated with titanium mesh cages filled with autologous cancellous iliac bone. After the affected disc and vertebral body resection with pus drainage, cadaveric allograft or titanium cages were inserted into the resected space. Posterior transpedicular screw fixation and rod compression in resected space, where cadaveric allograft or titanium cages were inserted, was performed to prevent the malposition in all patients except in 1 case. Recurrent infection was identified by serial erythrocyte sedimentation rate and cross reactive protein follow-up. Osseous union and recurred infection available at a minimum of 2 years following operation was identified. The amount of kyphosis correction and the subsidence were measured radiographically. RESULTS: Spinal fusion was achieved in 29 of 33 patients. In the cadaveric allograft group, 93.3% of patient (14 of 15) showed the osseous union while 83.3% of patient (15 of 18) in the titanium cage group showed union. Subsidence was noted in 12 of the patients. Twelve patients (36.3%) showed unsettling amounts of subsidence postoperatively whereas 46.6% of patients in the cadaveric allograft group and 37.7% of patients in the titanium cage group showed similar subsidence, respectively. There were statistical difference in the fusion rate (p=0.397) and subsidence rate (p=0.276) between the two groups. There was significant statistical difference in the postoperative improvement of segmental kyphosis between the two groups (p=0.022), that is the improvement in sagittal alignment was greater in the titanium cage group than in the cadaveric allograft group. There was no case of recurred infection. CONCLUSION: The cadaveric allograft and titanium cages are effective and safe in restoring and maintaining sagittal plane alignment without increased incidence in infection recurrence in pyogenic osteomyelitis. The postoperative improvement of segmental kyphosis was better in the cage group.

The Use of Titanium Mesh Cages in the Reconstruction of Anterior Column Defects in Active Spinal Infections: Can We Rest the Crest?

STUDY DESIGN: Retrospective clinical series. PURPOSE: To assess whether titanium cages are an effective alternative to tricortical iliac crest bone graft for anterior column reconstruction in patients with active pyogenic and tuberculous spondylodiscitis. OVERVIEW OF LITERATURE: The use of metal cages for anterior column reconstruction in patients with active spinal infections, though described, is not without controversy. METHODS: Seventy patients with either tuberculous or pyogenic vertebral osteomyelitis underwent a single staged anterior debridement, reconstruction of the anterior column with titanium mesh cage and adjuvant posterior instrumentation. The lumbar spine was the predominant level of involvement. Medical co-morbidities were seen in 18 (25.7%) patients. A significant neurological deficit was seen in 32 (45.7%) patients. At follow up patients were assessed for healing of disease, bony fuson, and clinical outcome was assessed using Macnab's criteria. RESULTS: Final follow up was done on 64 (91.4%) patients at a mean average of 25 months (range, 12 to 110 months). Pathologic organisms could be identified in 42 (60%) patients. Forty two (60%) patients had histopathological findings consistent with tuberculosis. Thirty of 32 (93.7%) patients showed neurological recovery. The surgical wound healed uneventfully in 67 (95.7%) patients. Bony fusion was seen in 60 (93.7%) patients. At final follow up healing of infection was seen in all patients. As per Macnab's criteria 61 (95.3%) patients reported a good to excellent outcome. CONCLUSIONS: Inspite of the theoretical risks, titanium cages are a suitable alternative to autologous tricortical iliac crest bone graft in patients with active spinal infections.

A Comparative Study of the Anterior Cervical Fusion with Harms Cage versus Iliac Bone Block: Clinical and Radiological Outcomes

STUDY DESIGN: A retrospective study. OBJECTIVES: To evaluate the clinical and radiological outcomes of anterior cervical fusion within Harms cage versus an iliac bone block graft. SUMMARY OF LITERATURE REVIEW: There is no current consensus regarding the optimal material for anterior cervical fusion. MATERIALS AND METHODS: This was a single-center study of 107 patients who either underwent anterior cervical fusion with an iliac bone block graft (n=56; group A) or a cancellous bone graft within the cervical Harms titanium cage (n=51; group B). Anterior plating occurred in all cases. Clinical outcomes and complications were evaluated using Visual Analogue Scale (VAS) scores and Odom's Criteria. Radiological outcomes were evaluated by the height of vertebral bodies, sagittal lordosis, the rate of bony union, and the subsidence of cage. RESULTS: The VAS of donor site pain was significantly higher in group A than in group B at the final follow-up. Sagittal lordosis was increased in both groups, but was significantly higher in group B than group A. The rate of bony union was 95% and 91% for both groups 6 months after surgery and reached 100% for both groups at the final follow-up. In terms of cage subsidence, the highest point of subsidence was at the inferior and posterior aspect of the cage and the average amount of subsidence was approximately 1.3 mm at final follow-up. CONCLUSIONS: Anterior cervical fusion using a cancellous bone graft within Harms titanium cage is a good method for anterior cervical fusion with iliac bone block.

Combining Uniplate anterior cervical plate system with titanium cage to treat single level cervical spondylotic myelopathy / 中国医师进修杂志

Objective To explore the value of combining Uniplate anterior cervical plate system with titanium cage to treat single level cervical spondylotic myelopathy. Method Observing the clinical outcome and X-ray results of 32 patients with cervical spondylotic myelopathy undergone anterior decompression, autograft fusion and internal fixation with Uniplate anterior cervical plate system and titanium cage. Results All patients were followed up for 3 to 12 months. According to bony fusion criteria,no implants breakage, dislocation or loosening was found in all cases in 3 months' postoperatively radiological review. According to Odom classification,excellent outcome was 27 patients, good was 5 patients, the excellent and good rate was 100%(32/32). Conclusions Combining Uniplate anterior cervical plate system with titanium cage to treat single level cervical spondylotic myelopathy has advantages of easy manipulation,safe, less complication and higher fusion rate. It is an ideal way for cervical anterior fixation.

Discectomía cervical anterior con artrodesis intersomática con cesta de titanio: experiencia en 102 casos (2002-2008)

La elevada frecuencia de pacientes con trastornos cervicales, ha llevado a estudiar estas afecciones, cuya diferenciación de otras enfermedades en muchas ocasiones resulta difícil. En la práctica neuroquirúrgica las enfermedades cervicales y degenerativas son unas de las más frecuentes, las hernias de columna cervical representan el segundo lugar de frecuencia de la patología discal. Este trabajo está basado en la revisión de la técnica de artrodesis cervical anterior posdiscectomía y fusión utilizando la cesta roscada de titanio, sin uso de injertos óseos, placas o tornillos, el cual es continuación de una revisión realizada dada la experiencia del autor en el 2004. Se analizan los procedimientos diagnósticos más frecuentemente utilizados y los criterios para la selección del tratamiento quirúrgico. Se presenta la experiencia en 102 casos. Las principales ventajas que ofrece esta técnica son: menor instrumentación; acortamiento del tiempo quirúrgico; estabilización inmediata de la columna cervical con recuperación y deambulación precoz de los pacientes, con retorno precoz a sus actividades normales, con mínimas complicaciones y reducción de costos

Cervical spinal degenerative and discal diseases are among the most common conditions encountered in medical practice. Herniated discs are more common in patients under 40 years of age and degenerative processes are more common after that age. In this study, the most common diagnostic methods and the current criteria for surgical management are reviewed. The author presents his experience of 102 cases with cervical discal and degenerative disease treated by discectomy and fusion through anterior approach, using the titanium cage without use of bone grafts, plates or screws. The main advantages of this technique include shortening of surgical time and fewer instrumentation, immediate stabilization of the cervical spine, early functional recovery and return to normal activities within two weeks with minimal complications, and lower cost

Posterior Lumbar Interbody Fusion Using Titanium Cages and Morselized Local Bone Autograft / 대한척추외과학회지

STUDY DESIGN: A retrospective study to evaluate the results of posterior lumbar interbody fusion (PLIF) using titanium cages filled with morselized local bone. OBJECTIVE: To verify the clinical and radiological results of the PLIF procedure using rectangular titanium cages filled with morselized local bone. SUMMARY AND LITERATURE REVIEW: Stabilization of the spine can be achieved by interbody arthrodesis through the posterior approach. However many significant problems including bone graft collapse, resorption, nonunion, and iliac donor site morbidity caused by the classic PLIF procedure need to be solved. The use of local bone and a titanium cage might be a solution. MATERIALS AND METHOD: Fifty-nine patients(average age at surgery, 51.3 years), who underwent surgery for degenerated low back disease, were enrolled in this study. The average follow-up duration was 19.9 months. The radiological fusion status, intervertebral disc heights, visual analogue scales, clinical outcomes were evaluated. RESULTS: Forty-three (73%) patients were classified as complete-union, 16 (27%) patients as probable-union, and no patients were classified as non-union. The average intervertebral disc height increased by 3.7 mm at immediate postoperatively, and the average subsidence was 1.1 mm at the final follow-up. The average visual analogue scale decreased from 5.5 to 1.4 for back pain and from 6.6 to 0.8 for radicular pain. Nineteen (32%) and 28 (48%) patients were classified as excellent and good, respectively, according to clinical outcome assessment by Kim and Kim criteria. The complications encountered were a dural tear in 8 patients, partial root injury in 1, and upper adjacent segment instability during follow-up in 2. CONCLUSION: PLIF using titanium cages filled with morselized local bone has the advantages of maintaining an intervertebral disc height, immediate stability, and the avoidance of donor site morbidity. However, longer-term results are needed, because the follow-up period of this study was relatively short

Preliminary Experiences with Interbody Titanium Cage(RABEA(TM)) Fusion in Patients with Degenerative Cervical Disease

OBJECTIVE: The purpose of this study is to evaluate the safety and efficacy of cervical interbody fusion with implantable titanium cage(RABEA(TM)). The authors retrospectively analysis the result of application of cervical hollow cage(RABEA(TM)) without bone graft to the patients of degenerative cervical disease. METHODS: 78 patients with radiculopathy with or without myelopathy due to degenerative cervical diseases were underwent anterior cervical discectomy and interbody fusion with titanium cages(RABEA(TM)) which were not filled with autogenous bone from June 1999 to December 2002. Among them, 33 patients could be followed-up for at least 6 months. Mean follow-up period was 13.3 months(ranged 6-30 months). RESULTS: Good or excellent results were found in approximately 82.0%. Preoperatively, the mean height of the disc space was 4.27mm(range 3~6mm), and at 1 day postoperatively it was 7.87mm(range 7~9mm). The mean height of the disc space after 1 year was 6.07mm(range 1~8mm). Due to subsidence of cage, 7 patients showed decrease of disc space height to preoperative disc space height. Among them, 1 patients showed poor results. A solid fusion was achieved in all patients. In this context, causes of subsidence are represented by osteoporosis and degree of cage recess. CONCLUSION: Titanium cages appear safe and effective in the treatment of degenerative cervical disease. But subsidence of cage, so far limited in number, appeared to be important risk factor for recurrence of the symptoms.

Preliminary Clinical Experience of Anterior Cervical Interbody Fusion with the AMSLU(TM) Cage

OBJECTIVE: The authors investigate the effectiveness and the demerits of the AMSLU(TM) cervical cage used in cervical spinal fusion for correction of cervical degenerative disc disease. METHODS: A total of 19 patients with cervical degenerative disc disease underwent anterior microdiscectomy and the AMSLU(TM) cage fusion. We made a retrospective comparative analysis between cases using the AMSLU(TM) cage and the classical autogenous iliac crest graft(AICG) with plate fixation about operative time, blood loss and hospital stay. The patient's neurological and functional outcomes were assessed on the basis of the modified Odom's criteria. RESULTS: The use of the AMSLU(TM) cage was found to save operative time(mean, 153+/-52min: P=0.004) and blood loss(mean, 236+/-171cc: P=0.032) as compared with the use of AICG. There was no donor-site complications and all patients were tolerable to ambulation at 1 day postoperatively. The patient's clinical success rate was 89% on discharge and 84% at 6 months postoperatively. CONCLUSION: The use of the AMSLU(TM) cage provides several advantages: no donor-site complications, brief instrument procedures, short operative time, small amount of blood loss and satisfactory clinical success rate. But it also has many limitations: short follow up period, kyphotic change and subsidence. Further investigations and clinical applications are necessary to use AMSLU(TM) cage in cases of spondylolisthesis and traumatic cervical disease.

Anterior Cervical Bisegmental Interbody Fusion with Titanium Cage(RABEA) in Degenerative Cervical Disease: Comparative Analysis with Monosegmental Interbody Fusion

OBJECTIVE: It is not uncommon to perform anterior discectomy for two adjacent disc levels in degenerative cervical disease due to diagnostic problems. The purpose of this study is to assess the effectiveness of titanium cage(RABEA) applied to two-level cervical degenerative disc disease, which is compared with the result of fusion with the same cage for one-level disc disease. METHODS: Between January 1999 and March 2003, 52 patients with degenerative cervical disease underwent anterior discectomy and interbody fusion with titanium cage(RABEA). Among them, 23 patients could be followed-up for more than 1 year. Ten patients received interbody fusion at one disc level(Group A), and 13 patients at two adjacent disc levels(Group B). Clinical outcome, fusion rate, disc space height and change of lordotic angle were analyzed in both groups. RESULTS: Clinical outcome according to Odom's criteria was excellent and good in 9(90%) of Group A and 11(84.6%) of Group B. The bone fusion rate of Group B was slightly lower than that of Group A. The height of disc space was well maintained until 1 year postoperatively in both groups. The change of the cervical lordotic angle has no significant difference between the two groups. CONCLUSION: Interbody fusion with titanium cage(RABEA) for two-level degenerative cervical disease may be an acceptable treatment modality due to relatively good clinical outcome despite slightly low fusion rate.