What is the fate of the adjacent segmental angles 6 months after single-level L3-4 or L4-5 lateral lumbar interbody fusion?

BACKGROUND CONTEXT: Lateral lumbar interbody fusion (LLIF) is an effective technique for fusion and sagittal alignment correction/maintenance. Studies have investigated the impact on the segmental angle and lumbar lordosis (and pelvic incidence-lumbar lordosis mismatch), however not much is documented regarding the immediate compensation of the adjacent angles. PURPOSE: To evaluate acute adjacent and segmental angle as well as lumbar lordosis changes in patients undergoing a L3-4 or L4-5 LLIF for degenerative pathology. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients included in this study were analyzed pre- and post-LLIF performed by one of three fellowship-trained spine surgeons, 6 months following surgery. OUTCOME MEASURES: Patient demographics (including body mass index, diabetes diagnosis, age, and sex) as well as VAS and ODI scores were measured. Lateral lumbar radiograph parameters: lumbar lordosis (LL), segmental lordosis (SL), infra and supra-adjacent segmental angle, and pelvic incidence (PI). METHODS: Multiple regressions were applied for the main hypothesis tests. We examined any interactive effects at each operative level and used the 95% confidence intervals to determine significance: a confidence interval excluding zero indicates a significant effect. RESULTS: We identified 84 patients who underwent a single level LLIF (61 at L4-5, 23 at L3-4). For both the overall sample and at each operative level, the operative segmental angle was significantly more lordotic postop compared to preop (all ps≤.01). Adjacent segmental angles were significantly less lordotic postop compared to pre-op overall (p=.001). For the overall sample, greater lordotic change at the operative segment led to more compensatory reduction of lordosis at the supra-adjacent segment. At L4-5, more lordotic change at the operative segment led to more compensatory lordosis reduction at the infra-adjacent segment. CONCLUSION: The present study demonstrated that LLIF resulted in significant increase in operative level lordosis and a compensatory decrease in supra- and infra-adjacent level lordosis, and subsequently no significant impact on spinopelvic mismatch.

The role of traditional growing rods in the era of magnetically controlled growing rods for the treatment of early-onset scoliosis.

PURPOSE: To describe the clinical and radiographic profile of early-onset scoliosis (EOS) patients treated with traditional growing rods (TGR) during the magnetically-controlled growing rod (MCGR) era. METHODS: A US multicenter EOS database was reviewed to identify (1) patients who underwent TGR after MCGR surgery was introduced at their institution, (2) patients who underwent MCGR during the same time period. Of 19 centers, 8 met criteria with all EOS etiologies represented. Clinical notes were reviewed to determine the indication for TGR. Patient demographics and pre-operative radiographs were compared between groups. RESULTS: A total of 25 TGR and 127 MCGR patients were identified. The TGR patients were grouped by indication into the sagittal plane profile (n = 11), trunk height (n = 6), co-morbidities/need for MRI (n = 4), and other (ex: behavioral issues, remaining growth). Four patients had a combination of sagittal profile and short stature with sagittal profile listed as primary factor. The TGR short trunk group had a mean T1-S1 length of 192 mm vs 273 mm for the MCGR group (p = 0.0002). The TGR sagittal profile group, had a mean maximal kyphosis of 61° vs 55° for the MCGR group (p = 0.09). CONCLUSION: TGR continues to have a role in the MCGR era. In this study, the most commonly reported indications for TGR were sagittal plane profile and trunk height. These results suggest that TGR is indicated in patients of short stature with stiff hyperkyphotic curves. As further experience is gained with MCGR, the indications for TGR will likely be refined.

The 15-Year Evolution of the Thoracoscopic Anterior Release: Does It Still Have a Role?

STUDY DESIGN: Retrospective. PURPOSE: To determine how the indications for anterior thoracoscopic release and fusion have evolved over time. OVERVIEW OF LITERATURE: Anterior release was commonly performed to correct severe spinal deformities before the advent of pedicle screw fixation. The thoracoscopic approach significantly reduced the morbidity, as compared to open thoracotomy procedures. METHODS: We reviewed charts and radiographs of pediatric spinal deformity patients who underwent thoracoscopic release/fusion for their deformity from 1994 to 2008. Indications for the thoracoscopic procedure were assigned to one of the following categories: hyperkyphosis, large/stiff scoliosis, crankshaft prevention, and 'other'. We analysed indications grouped in 3-year intervals to determine how the indications for this procedure evolved over the past 15 years. RESULTS: One hundred and thirty-eight patients (mean age, 15 years; range, 2-28 years) underwent the procedure, with 160 identified indications. The frequency of thoracoscopic anterior release/fusion decreased after peaking in the years 2000-2002. Initially, hyperkyphosis was the most frequent indication (15/33, 45%; 1994-1996), but declined to an intermittent indication since 2006. The use of thoracoscopy to prevent crankshaft has also declined, but remains an indication for the most immature cases (2/17, 12%; 2006-2008). Severe or rigid scoliosis is currently the most common indication for thoracoscopic release/fusion at our center (11/17, 65%; 2006-2008). CONCLUSIONS: The indications for a thoracoscopic anterior release/fusion has evolved with our increased understanding of this procedure and improved posterior fixation with pedicle screw instrumentation. Thoracoscopy in select spinal deformity patients still has an important role despite its less frequent use, as compared to the past decade.

Negative pressure therapy for closed spine incisions: a pilot study.

UNLABELLED: Negative pressure therapy (NPT), used on open wounds or postoperative infections, has not been evaluated on closed spinal incisions. This was analyzed after 3 days and 5 days of NPT application using biomechanics and histology in a porcine model. METHODS: In 8 mature miniature pigs, 2 end-to-end midline spine incisions were closed in a standard fashion. Negative pressure (Prevena™ Incision Management System, KCI, San Antonio,TX) was applied to one incision (NPT group) while standard dry dressings were used on the other (control group). After 3 days or 5 days, all incisions underwent biomechanical (eg, failure load, failure energy, and stress), histological, and scar scale evaluation. ANALYSIS: ANOVAs compared the groups (3-day vs 5-day, NPT vs control, P < 0.05). Negative pressure therapy demonstrated a significantly improved scar scale height grade than the control (P = 0.026). Failure load (4.9 ± 4.0 vs 16.5 ± 14.6 N), energy absorbed (8.0 ± 9.0 vs. 26.9 ± 23.0 mJ), and ultimate stress (62 ± 53 vs. 204 ± 118 N/mm2) were lower in the control group. Histological analysis revealed no differences in incision scar width. CONCLUSION: Negative pressure therapy application on closed incisions presented a trend toward improved early healing strength, and in significantly improved incision appearance. Clinically, NPT may improve incision integrity, minimizing the risk of dehiscence or subsequent infection. Patients at high risk of postoperative incision site complications may benefit from primary application of NPT.

Isocentric reattachment of ligamentum teres: a porcine study.

BACKGROUND: Recent reports reveal interest in the mechanical importance of ligamentum teres (LT) in hip dislocation. In the previously established procedure of anteroinferior acetabular LT reattachment in developmental dysplasia of the hip, the LT functions as a check-rein, showing promising results. However, this position of reattachment could potentially limit motion. The purpose of this study was to evaluate the feasibility of an isocentric point for reattachment of the LT and to study its impact on hip function using a young porcine model. METHODS: Pelvic specimens with intact anatomy were obtained from 6 skeletally immature pigs (12 hips). Through a careful anteromedial capsulotomy, the LT was detached from its acetabular insertion then reattached to 1 of 2 positions: (1) anteroinferior lip of the acetabulum; (2) proposed isocentric position. Intra-articular stress distribution was measured through a complete range of motion with a prescale Fuji pressure film. Tension was then applied to the LT and the stresses were recorded again. In addition, radioopaque solution was injected into the substance of the LT, then floroscopy tracked the LT location initially and after the 2 reattachment positions through a full hip range of motion. RESULTS: Reattachment of the LT at an isocentric point is feasible in a pig model. With careful physiologic tensioning of this reattachment, hip can maintain full motion with no excessive pressure areas created within the joint. On the contrary, the initial technique of anteroinferior extra-articular attachment limits external rotation and extremes of abduction. We found this LT tracking technique (with radioopaque dye injection) to be reliable and reproducible. CONCLUSIONS: The isocentric reattachment of the LT is feasible in this pig model and serves as a natural check-rein to dislocation without limiting joint motion or causing abnormal cartilage pressures. CLINICAL RELEVANCE: Isocentric LT reattachment may provide a method for improving stability of open reductions when treating children with such conditions.

Intracapsular hip pressures in a porcine model: does position and volume matter?

This study outlines a relationship between joint volume, positioning, and intracapsular pressure in a healthy hip. After measuring the native intracapsular pressure in 12 porcine specimens, each joint was injected with radio-opaque-colored saline as pressures were measured. At 20 mmHg, the hip was placed in its position of ease and then in differing positions while pressures were recorded. Position significantly altered pressures, with the lowest values in neutral and the highest in hyperextension (P<0.001). Extreme hip positions may be detrimental because of high pressures created within the joint, possibly explaining complications associated with some hip diagnostic and treatment methods.

Spinal supports and physical therapy in patients with low back pain: a case series.

UNLABELLED: The association of low back pain with physical workload in seated workstation related jobs has been debated and remains controversial. Clinical studies eliciting the natural history of the disease in this emerging population are insufficient to make definitive conclusions. We report four consecutive cases of patients suffering from low back pain presenting to a tertiary spine clinic with severe non-specific low back pain. Two patients as age-matched controls with persistent low back pain were followed for 6 months after receiving conventional treatment. In comparison, two test patients received parallel conventional treatment along with orthopaedic full spinal supports as an additional treatment modality. Outcomes analysed demonstrate the efficacy of orthopaedic full spinal supports for treating low back pain. TRIAL REGISTRATION NUMBER: NCT00553540.

Role of patient-based health status outcome measurements in opioid management for low back pain.

OBJECTIVE: The aim of the study was to identify patient factors that correlate with a strong response to opioid pain medications in low back pain patients. DESIGN: Prospective analysis. SETTING: Tertiary Institutional Spine Care Center. PATIENTS, PARTICIPANTS: All patients visiting a tertiary referral spine center with primary diagnosis of low back pain (n = 486) and minimum duration of 6 months. INTERVENTIONS: Opioid medication. MAIN OUTCOME MEASURES: Analysis factors included visual analog pain scale (VAS), symptom relief scores, and results on 36-item Short Form Health Survey (SF-36). A longitudinal descriptive analysis and a multivariable logistic regression were performed on the results of the VAS and SF-36 scores. RESULTS: The average age of opioid and nonopioid treated patients was 62 years versus 64 years, (p = 0.13) and gender distributions at 53 percent versus 50 percent female (p = 0.43). SF-36 scores were statistically significant and associated with the opioid categorization. For every unit increase in symptom relief score, the likelihood of opioid use is doubled (OR = 2.1, 95 percent CI = 1.5-2.8, p < 0.001); and increased by 25 percent with each 10-point decrease in the social functioning quality of life score (OR = 0.98, 95 percent CI = 0.96-0.99, p = 0.006). CONCLUSIONS: Social quality of life and symptom relief measurements comprise the optimal set of independent factors that correlate most strongly with a response to opioid use in low back pain patients.