AOA Critical Issues: Promoting Leadership Development Among Orthopaedic Faculty.

ABSTRACT: All orthopaedic surgeons are leaders in the operating room and clinic, and many orthopaedic surgeons choose to pursue other formal leadership roles. Effective leaders are proficient communicators, have high emotional intelligence, have a growth mindset, create structure, and facilitate teamwork. Participating in formal leadership training offered through the American Orthopaedic Association, the American Academy of Orthopaedic Surgeons, or advanced degree programs can facilitate the development of leadership skills. By setting goals, being aware of available leadership positions, and promoting diversity, senior leaders may help orthopaedic faculty to achieve senior leadership roles. Maxwell's leadership hierarchy, which consists of 5 levels of leadership (position, permission, production, people development, and pinnacle), provides a framework for the promotion and mentorship of junior partners by senior leaders. Seeking out and promoting leadership will encourage an environment of leaders and improve the field of orthopaedic surgery.

Catastrophic acute failure of pelvic fixation in adult spinal deformity requiring revision surgery: a multicenter review of incidence, failure mechanisms, and risk factors.

OBJECTIVE: There are few prior reports of acute pelvic instrumentation failure in spinal deformity surgery. The objective of this study was to determine if a previously identified mechanism and rate of pelvic fixation failure were present across multiple institutions, and to determine risk factors for these types of failures. METHODS: Thirteen academic medical centers performed a retrospective review of 18 months of consecutive adult spinal fusions extending 3 or more levels, which included new pelvic screws at the time of surgery. Acute pelvic fixation failure was defined as occurring within 6 months of the index surgery and requiring surgical revision. RESULTS: Failure occurred in 37 (5%) of 779 cases and consisted of either slippage of the rods or displacement of the set screws from the screw tulip head (17 cases), screw shaft fracture (9 cases), screw loosening (9 cases), and/or resultant kyphotic fracture of the sacrum (6 cases). Revision strategies involved new pelvic fixation and/or multiple rod constructs. Six patients (16%) who underwent revision with fewer than 4 rods to the pelvis sustained a second acute failure, but no secondary failures occurred when at least 4 rods were used. In the univariate analysis, the magnitude of surgical correction was higher in the failure cohort (higher preoperative T1-pelvic angle [T1PA], presence of a 3-column osteotomy; p < 0.05). Uncorrected postoperative deformity increased failure risk (pelvic incidence-lumbar lordosis mismatch > 10°, higher postoperative T1PA; p < 0.05). Use of pelvic screws less than 8.5 mm in diameter also increased the likelihood of failure (p < 0.05). In the multivariate analysis, a larger preoperative global deformity as measured by T1PA was associated with failure, male patients were more likely to experience failure than female patients, and there was a strong association with implant manufacturer (p < 0.05). Anterior column support with an L5-S1 interbody fusion was protective against failure (p < 0.05). CONCLUSIONS: Acute catastrophic failures involved large-magnitude surgical corrections and likely resulted from high mechanical strain on the pelvic instrumentation. Patients with large corrections may benefit from anterior structural support placed at the most caudal motion segment and multiple rods connecting to more than 2 pelvic fixation points. If failure occurs, salvage with a minimum of 4 rods and 4 pelvic fixation points can be successful.

Alternative Uses of O-Arm and Stealth Navigation Technology Over 10 Years: The University of Colorado Experience.

Intraoperative computed tomography scanning with O-arm and use of Stealth navigation can improve surgical outcomes in a variety of orthopedic subspecialties. In spine surgery, the accuracy, precision, and safety of pedicle screw and interbody implant placement has improved. This technology is now routinely used in percutaneous pedicle screw placement and minimally invasive sacroiliac joint fusion. Other applications include, but are not limited to, isthmic pars defect repair, lumbosacral pseudoarticulation resection in Bertolotti's syndrome, radiofrequency ablation, and en bloc tumor resection. Intraoperative navigation has numerous applications, and use of this technology should continue to evolve as the technology advances. [Orthopedics. 2023;46(2):e89-e97.].

Osteoporosis: An Update on Screening, Diagnosis, Evaluation, and Treatment.

Osteoporosis screening, diagnosis, and treatment have gained much attention in the health care community over the past 2 decades. During this time, creation of multispecialty awareness programs (eg, "Own the Bone," American Orthopedic Association; "Capture the Fracture," International Osteoporosis Foundation) and improvements in diagnostic protocols have been evident. Significant advances in technology have elucidated elements of genetic predisposition for decreased bone mineral density in the aging population. Additionally, several novel drug therapies have entered the market and provide more options for primary care and osteoporosis specialists to medically manage patients at risk for fragility fractures. Despite this, adherence to osteoporosis screening and treatment protocols has been surprisingly low by health care practitioners, including orthopedic surgeons. Continued awareness and education of this skeletal disorder is crucial to effectively care for our aging population. [Orthopedics. 2023;46(1):e20-e26.].

Blockade of Osteoclast-Mediated Bone Resorption With a RANKL-Inhibitor Enhances Bone Formation in a Rat Spinal Fusion Model.

STUDY DESIGN: Rat spine fusion model. OBJECTIVE: The present study aimed to determine whether administration of osteoprotegerin (OPG) in a rat model of spinal fusion increases bone volume, bone density, and decreases osteoclasts in the fusion mass. SUMMARY OF BACKGROUND DATA: OPG is a soluble RANK-ligand inhibitor that blocks osteoclast differentiation and activation. This makes it a potential agent to control the remodeling process and enhance bone mass during spinal fusion. MATERIALS AND METHODS: Forty-eight male Sprague-Dawley rats received a one-level spinal fusion of L4-L5 with bone allograft. Rats were then divided into four groups according to initiation of treatment: (1) saline on day 0 (saline), (2) OPG on day 0 (OPG D0), (3) OPG on day 10 (OPG D10), and (4) OPG on day 21 (OPG D21) postsurgery. After their initial injection, rats received weekly subcutaneous injections of OPG (10 mg/kg) and were euthanized six weeks postsurgery. MicroCT analysis of the fusion site and histological analysis of bone surface for quantification of osteoclast lining was performed. RESULTS: Increased bone volume in the fusion site and around the spinous process was seen in OPG D0 and OPG D10 when compared with saline. Mean trabecular thickness was greater in all groups receiving OPG compared with saline, with OPG D0 and OPG D10 having significantly greater mean trabecular thickness than OPG D21. All OPG groups had less bone surface lined with osteoclasts when compared with Saline, with OPG D0 and OPG D10 having fewer than OPG D21. CONCLUSIONS: This study indicates that OPG inhibited osteoclast bone resorption, which led to greater bone at the fusion site. Future studies investigating OPG on its own or in combination with an osteogenic factor to improve spinal fusion outcomes are warranted to further elucidate its potential therapeutic effect.

Pre-Operative Planning in Complex Deformities and Use of Patient-Specific UNiD™ Instrumentation.

STUDY DESIGN: Review of current literature and authors experience. OBJECTIVE: Pre-operative planning is an integral part of complex spine surgery. With the advent of computer-assisted planning, multiple surgical plans can be evaluated utilizing alignment parameters, and the best plan for individual patients selected. However, the ability to evaluate and measure surgical correction goals intraoperatively are still limited. The use of patient-specific UNiD rods, created based on pre-operative plans, provided an initial tool for implementation of pre-operative plans in the operative setting. METHODS: A literature review for the use of patient-specific UNiD rods in thoracolumbar spine complex surgery was performed. The articles were selected and reviewed for the initial experience/outcomes of these techniques. Further, the initial experience of the authors at The University of Colorado is described. RESULTS: The use of UNiD patient-specific rods, in combination with pre-operative planning has been shown to provide a higher rate of patients with spinopelvic alignment parameters within currently accepted ranges. This includes improvement of sagittal vertical axis (SVA) < 50 mm and pelvic incidence (PI)-lumbar lordosis (LL) = ± 10°. Multiple authors have shown improvement in pelvic tilt to age adjusted values but note continued difficulties in obtaining correction goals. CONCLUSIONS: The use of pre-operative planning software and UNiD patient-specific rods has been shown to improve surgeon's ability to achieve spinopelvic alignment parameters, specifically SVA and PI-LL, along with other possible benefits. Further research is needed regarding long-term value of the technology.

The University of Colorado Virtual Physical Examination for Spine Surgeons: A Preliminary Study.

As coronavirus disease 2019 (COVID-19) reached pandemic status, in-person orthopedic clinics across the United States were forced to close as many states adopted stay-at-home orders. Previously, the use of telemedicine in orthopedic practices was minimal for a variety of reasons, one being the inability to perform a physical examination in a specialty reliant on direct patient contact for diagnosis and treatment. A prospective cohort of 52 patients consented to participate in a novel virtual physical examination protocol during routine telemedicine visits at a large, tertiary orthopedic spine practice. Participants were asked to perform a series of carefully designed physical maneuvers using readily available household objects to allow their provider to better assess sensory and motor function in the tele-medicine setting. Patients were then asked to complete a short satisfaction survey. In total, 52 patients completed the physical examination and survey. Males and females were distributed evenly among the cohort at 50%. The mean age was 52.1±15.5 years. The average score for ease of understanding the examination (1=easiest, 5=hardest) was 1.1, while the average score for ease of performance was 1.5. Most participants (97.56%) felt their provider was better able to understand their condition using the virtual examination findings. This study highlights the utility of a virtual physical examination for assessment of spine patients in the telemedicine setting. Furthermore, this study illustrates the ease with which such an examination can be implemented and performed to improve patient evaluation and satisfaction. [Orthopedics. 2022;45(1):e7-e10.].

Laser Marking of Spine Rods Is Strongly Associated With Risk of Clinical Rod Failure.

INTRODUCTION: What is overlooked in clinical studies are the possibilities of manufacturing and design aspects of the instrumentation that could initiate rod fracture. Although revision because of hardware fracture is a small fraction of the overall revision rates (12.1% to 13.7%), there are sufficient numbers of revision cases where hardware removed can undergo a thorough metallurgic analysis. This study is unique in that rod characteristics, such as alloy, surface markings, and fracture type, seen at fracture surfaces are considered in the analysis. METHODS: This work was conducted under both a retrospective and prospective IRB. Patients considered for this study were between the ages of 18 and 85 years who underwent or were undergoing revision spine surgery with previous instrumentation in the cervical, thoracic, or lumbar region and evidence of at least one of the following: catastrophic hardware failure, pseudarthrosis, implant loosening, or nonfusion. Inclusion criteria were determined through radiographic and medical records review. RESULTS: Fifty-six patients who had revision procedures because of different indications were included; 101 rods were removed, tested for fracture, and included in the analysis. Laser marking is significantly (P < 0.0001) associated with rod fracture. Detailed analysis showed notable surface and subsurface changes as the result of the marking, such as surface melting, cracking, and notching, creating locations to initiate a fracture. The three most informative variables to clinical rod fracture using multiple regression modeling were body mass index, presence or absence of laser mark (yes/no), and length of posterior fusion (≤2 spinal levels/>2 spinal levels). It was found that the relative risk of rod fracture is 23 times higher during 20 postoperative years than in cases with this index <0.4. DISCUSSION: For a patient with a given body mass index, if they require a multilevel fixation greater than two levels and rods with laser marks are used, the risk of early rod fracture increases by 40%.

Postoperative pelvic incidence (PI) change may impact sagittal spinopelvic alignment (SSA) after instrumented surgical correction of adult spine deformity (ASD).

OBJECTIVES: To study factors causing postoperative change of PI after surgical correction of ASD and to assess the effect of this variability on postoperative PI-LL mismatch. BACKGROUND: PI is used as an individual constant to define lumbar lordosis (LL) correction goal (PI-LL < 10). Postoperative changes of PI were shown but with opposite vectors. The impact of the PI variability on the postoperative PI-LL has not been studied. METHODS: The medical and radiographic data analyzed for patients who underwent long posterior instrumented spinal fusion. Inclusion criteria are age, ≥ 20 years old; ASD due to degenerative disk disease (DDD) or scoliosis (DS); ≥ 3 levels fused; and 2-year follow-up or revision. Studied parameters are LL (L1-S1), PI, sacral slope (SS), pelvic tilt (PT), and PI-LL. Measurement error and postoperative changes were defined. Statistical analysis includes ANOVA, correlation, regression, and risk assessment by odds ratio; P ≤ 0.05 considered statistically significant. RESULTS: Eighty patients were included: mean age, 62.4 years-old (SD, 11.1); female, 63.7%; mean body mass index (BMI), 27.1 (SD, 5.6). Distribution of patients by follow-ups includes preoperative 100%; postoperative (1-3 weeks), 100%; 11-13 months. 90%; 22-26 months, 58%; and revision: 24%. Pre- versus postoperative PI (∆PI) changed both positively and negatively and the absolute value of change|∆PI| exceeded measurement error (P ≤ 0.05) reaching as high as 31°, and progressed with time; R2 dropped from 0.73 to 0.45 (P < 0.001); ∆PI depended on disproportional changes of SS and PT, preoperative PI, and change of LL. Obesity, DS, and absence of sacroiliac fixation increased |∆PI|. The risk of LL insufficient correction (PI-LL > 10°) associated with a |∆PI|> 6°, P = 0.05. Sacroiliac fixation diminished PI variability only during the first postoperative year. CONCLUSION: Preoperative variability and postoperative instability of PI diminish the applicability of the PI-LL < 10° goal to plan correction of LL. An alternative method is offered. LEVEL OF EVIDENCE: IV.

Toxicology Screening Testing in Patients Undergoing Spine Surgery: A Prospective Observational Pilot Study.

BACKGROUND: Chronic opioid use and polypharmacy are commonly seen in chronic pain patients presenting for spine procedures. Substance abuse and misuse have also been reported in this patient population. Negative perioperative effects have been found in patients exposed to chronic opioid, alcohol, and recreational substances. Toxicology screening testing (TST) in the perioperative period provides useful information for adequate preoperative optimization and perioperative planning. METHODS: We designed a pilot study to understand this population's preoperative habits including accuracy of self-report and TST-detected prescribed and unprescribed medications and recreational substances. We compared the results of the TST to the self-reported medications using Spearman correlations. RESULTS: Inconsistencies between TST and self-report were found in 88% of patients. Spearman correlation was 0.509 between polypharmacy and intraoperative propofol use, suggesting that propofol requirement increased as the number of substances used increased. CONCLUSIONS: TST in patients presenting for spine surgery is a useful tool to detect substances taken by patients because self-report is often inaccurate. Discrepancies decrease the opportunity for preoperative optimization and adequate perioperative preparation.

Corrosion of Titanium Spinal Explants Is Similar to That Observed in Oil Field Line Pipe Steel: Evidence of Microbial-Influenced Corrosion In Vivo.

Current explanations of biomedical alloy degradation are focused on the physicochemical mechanisms of galvanic, pitting, crevice, and fretting corrosion. Ultimately, these studies dismiss the corrosion mechanism as a function of the local microbiome. Sixty spine hardware constructs were examined immediately after explantation for biofilm formation. Marked rod sections were imaged using scanning electron microscopy with energy dispersive x-ray spectroscopy. Backscatter mode was employed to better image the topology of the surface. There is clear differentiation between discoloration due to corrosion vs mechanical damage. Under scanning electron microscopy backscatter electron shadow examination, the authors noted that not all biofilm was removed using the surgical wipes. Corrosion pits were noticeably larger and numerous in areas of biofilm. In areas not associated with biofilms, there were few pits even if mechanical wear was evident. There is no evidence that the surface corrosion is modified between clinically diagnosed infected and noninfected patients. The surface damage present on explanted Ti6Al4V spine rods is uniquely similar to damage found in other industries where microbial-influenced corrosion is prevalent. Given that similar anaerobic, sulfur-reducing bacteria reside in and on human tissues, it is most likely that corrosion observed on explanted hardware is the result of microbial-influenced corrosion and not from inflammatory or other processes. Using analysis methods from other industries to characterize the microbiome present on explanted hardware is necessary. In so doing, a new definition of hardware-induced infection will be forthcoming. [Orthopedics. 2020;43(1):62-67.].

Radius of Curvature in Patient-Specific Short Rod Constructs Versus Standard Pre-Bent Rods.

BACKGROUND: Recent studies support the need for sagittal alignment restoration when performing lumbar degenerative spinal fusions. The development of patient-specific spine rods (PSSRs) may help maintain or improve sagittal alignment in these surgeries. METHODS: A retrospective review was conducted for patients who underwent posterior spinal surgeries involving 4 or less levels. The preplanned PSSR radii of curvature (ROC) was compared with standard prebent rods with a ROC of 125 mm. All surgeries were performed at a single institution by 3 surgeons from September 2016 through October 2018. Data were then compared using a 2-tailed paired t test. PSSR had either 1 or 2 definitive ROCs. RESULTS: For rods with 2 ROCs, the "cranial" curve was measured between the upper instrumented level and L4 or L5. The "caudal" curve was measured between L4 or L5 and the lower instrumented level. The PSSR with 1 ROC and the caudal portion of the rods with 2 ROCs were significantly smaller than the industry standard ROC. CONCLUSIONS: PSSR demonstrate more acute ROC than industry standard rods. In PSRs, the most lordosis occurs between L4-S1 and flattens out at the thoracolumbar junction, mimicking the normal distribution of lumbar lordosis. PSSRs could help achieve or maintain sagittal alignment and prevent the sequela of flat back syndrome.

Validation of Pre-operative Templating for Total Disc Replacement Surgery.

OBJECTIVES: This was an analytic retrospective observational study. The aims were (1) to validate patient-specific templating process by comparing postoperative range of motion (ROM) with that predicted by the model, (2) to retrospectively determine the ideal implant size, height, configuration, and location to evaluate if the ROM achieved could have been improved, and (3) to correlate postoperative ROM and clinical outcome. BACKGROUND: Previous research revealed that after total disc replacement surgery, 34% of patients with less than 5° of postoperative ROM developed adjacent segment disease. The match between patient anatomy (size, facet orientation, disc height) and implant parameters are likely to affect postoperative ROM and clinical outcomes. METHODS: Seventeen consecutive patients were implanted with 22 ProDisc-L devices between 2008 and 2015. Three-dimensional finite element (FE) models of the implanted segment were constructed from preoperative computed tomography scans and virtually implanted with the ProDisc-L implant. ROM was determined with the endpoints of facet impingement in flexion and implant contact in extension. FE templating was used to determine the optimal implant size and location. ROM was then measured directly from flexion and extension radiographs and compared to predicted ROM. Pre and postoperative Oswestry Disability Index (ODI) data were used to correlate ROM with clinical outcomes. RESULTS: No significant difference was found between the actual and predicted ROM. The computational templating procedure identified an optimal ROM that was significantly greater than actual ROM. The ROM in our cohort could have been improved by an average of 1.2° or 12% had a different implant size or position been used. CONCLUSIONS: FE analyses accurately predicted ROM in this cohort and can facilitate selection of the optimal implant size and location that we believe will increase the chance of achieving clinical success with the application of this technology.

The Prevalence of the Use of MIS Techniques in the Treatment of Adult Spinal Deformity (ASD) Amongst Members of the Scoliosis Research Society (SRS) in 2016.

STUDY DESIGN: Electronic survey administered to Scoliosis Research Society members. OBJECTIVE: To determine the prevalence of minimally invasive surgery (MIS) techniques for the treatment of adult spinal deformity. SUMMARY OF BACKGROUND DATA: There is a paucity of data available on the practice pattern, prevalence of minimally invasive spine surgery, and the preferred minimally invasive techniques in the treatment of adult spine deformity. METHODS: An electronic nine-question survey regarding individual usage pattern of minimally invasive spine surgery techniques was administered in 2016 to the members of the Scoliosis Research Society. Determinants included complexity in condition of patient population, prevalence of use of minimally invasive techniques in the surgeon's practice, prevalence of use of a particular MIS technique, strategy elected during surgery, adoption of staging of procedures and timing between staging of procedures. RESULTS: A total of 357 surgeons responded (61.3% response rate), and 154 (43.1%) of the respondents said that they use MIS as a part of their surgical treatment of adult spinal deformity. However, of these 154 respondents, 67 (43.5%) said that their MIS usage in deformity practice was between 1% and 20%. Only 11 (7.2%) said that they used MIS 81% to 100% of the time. The top MIS approaches that surgeons chose were MIS lateral lumbar interbody fusion 109 (70.59%) and MIS percutaneous screws 91 (58.8%). CONCLUSIONS: The low rate of adoption of these techniques among the SRS members may be due to the false perception that there is not enough data to support that MIS techniques are better. This and the fact that a practitioner needs to be facile at different MIS techniques may be the true impediment to the adoption of MIS techniques in the treatment of ASD. LEVEL OF EVIDENCE: Level IV.

Patient-specific Rods for Surgical Correction of Sagittal Imbalance in Adults: Technical Aspects and Preliminary Results.

STUDY DESIGN: This was an innovative concept and a preliminary prospective series. OBJECTIVE: The aim of this study was to present the concept and the technical aspects of patient-specific rods (PSR), and compare preoperative and postoperative sagittal parameters (after PSR implantation), with a special focus on the difference pelvic incidence (PI)-lumbar lordosis (LL). BACKGROUND: Despite established techniques for planning and proven correlations between quality of life and sagittal alignment, some patients do not achieve optimal radiologic outcomes after surgery and are still hypolordotic and imbalanced. We hypothesize that the use of PSR could improve the correspondence between planning and surgical realization. METHODS: The planning was based on spinopelvic parameters evaluated on a full-spine x-ray. The surgical procedure including osteotomies was simulated using a dedicated program to reach the following objectives: PI-LL<10 degrees, a pelvic tilt <20 degrees, and sagittal vertical axis <50 mm. From the virtually corrected spine, the rod curvature and length were defined. Two PSRs were thus precisely manufactured and bent to this specification. Adults with degenerative spinal disorders requiring a construct ≥5 levels were implanted with PSR and prospectively included. We compared ratios through the χ test. RESULTS: A total of 60 patients (mean age of 64.4 years old; range, 34-83) were included. Follow-up was carried out over a period of 1 year. Average pedicle screws construct was of 6.4 levels (range, 5-9). Eight patients underwent a pedicle subtraction osteotomy. PI-LL was <10 degrees at baseline in 29/60 patients, and at follow-up in 50/60 (odds ratio=5, P=E-5). CONCLUSIONS: The ratio of patients with optimal PI-LL improved significantly from PSR implantation. In comparison with published data for conventional surgery, patients implanted with PSR were 2.6 times more likely to be optimally corrected. The expected benefits of PSR include the optimal execution of the plan, decreased mechanical complications, and reduced operating time, no longer requiring the bending of rods during surgery. A randomized trial on sagittal correction using PSR is ongoing.

Pelvic Incidence Changes Between Flexion and Extension.

STUDY DESIGN: Retrospective single-center. OBJECTIVES: To investigate changes in pelvic incidence from flexion to extension. To assess interobserver error in the measurement of pelvic incidence. BACKGROUND: Pelvic incidence (PI) has been considered a static parameter since it was originally described. But recent studies have shown that PI can change with age and after spinal procedures. Changes in PI based on position have not been investigated. METHODS: Seventy-two patients who had obtained flexion and extension radiographs of the lumbar spine were identified using strict inclusion and exclusion criteria. PI along with pelvic tilt (PT), sacral slope (SS), and lumbar lordosis were measured in both flexion and extension by two independent measurers. Variations in all parameters and interobserver measurement reliability were analyzed for the entire group. RESULTS: PI changed significantly from flexion to extension with a general tendency to decrease: mean (-0.94°), p <.044. However, these changes might have had opposite vectors, and exceeded | 6°| (measurement error) in 20% of cases, with a maximum of 12°. Inconsistencies in changes of SS, as opposed to PT from flexion to extension, were found to be the major factor determining changes in PI (p >.001). Obesity significantly contributed to differences in PI between flexion and extension (p = .003). CONCLUSIONS: PI is a dynamic parameter that changes between flexion and extension. Changes in SS are the main factor involved in these changes, implicating movement through the sacroiliac joints as the cause. Obese patients have greater changes in PI from flexion to extension. LEVEL OF EVIDENCE: Level II.

Surgical Intervention for Cauda Equina Syndrome in the Second and Third Trimesters of Pregnancy: A Report of Three Cases.

CASE: Low back pain affects >50% of pregnant women. However, cauda equina syndrome (CES) during pregnancy is rare. Because a delay in treatment increases the risk of irreversible neurologic damage, acute onset is regarded as a surgical emergency. We describe 3 cases of CES in pregnant women at 24, 27, and 30 weeks' gestation, respectively. CONCLUSION: All 3 of the patients underwent surgical decompression in the prone position under general anesthesia with continuous external monitoring of the fetal heart rate. Intraoperative findings were noteworthy for epidural venous plexus engorgement in 2 of the patients. There were no complications for the patients or the fetuses, and all 3 of the patients had postoperative resolution of the neurologic symptoms.

Stand-alone Anterior Lumbar Interbody, Transforaminal Lumbar Interbody, and Anterior/Posterior Fusion: Analysis of Fusion Outcomes and Costs.

Fusion outcomes and costs of stand-alone anterior lumbar interbody fusion (ALIF), transforaminal lumbar interbody fusion (TLIF) in association with posterior fusion, and anterior/posterior (A/P) fusion were compared using clinical, radiographic, and billing data. Adult patients with symptomatic 1- or 2-level degenerative disk disease in isolation or in association with a grade 1 or 2 degenerative or lytic spondylolisthesis and canal and/or foraminal stenosis who underwent elective stand-alone ALIF, TLIF, or A/P fusion were compared. The analysis focused primarily on fusion rates and costs and secondarily on radiographic and clinical parameters. One hundred six patients at least 2 years beyond surgery (ALIF, 53; TLIF, 17; A/P fusion, 36) were reviewed. Demographics were similar except for age, with the ALIF group being younger (mean, 37.8 years) than the other groups (TLIF, 53.1 years; A/P fusion, 48.2 years). There were no differences between the groups in fusion rates or outcomes as assessed by the Numeric Rating Scale. Compared with the other 2 groups, the ALIF group had a significantly shorter operative time, less blood loss, and a shorter stay (P<.0001). Evaluation of radiographic parameters revealed significant differences regarding disk angle (P<.001), disk height (P<.0001), and pelvic tilt (P=.001) favoring ALIF and A/P fusion over TLIF. Stand-alone ALIF should be considered in the management of patients with 1- or 2-level lumbar degenerative disk disease for which the pathology can be addressed adequately via this approach. [Orthopedics. 2018; 41(5):e655-e662.].

Development of Bilateral Facet Cysts Causing Recurrent Symptoms After Decompression and the Placement of an Intralaminar Implant: A Case Report.

CASE: We report the development of bilateral symptomatic facet joint cysts in a 78-year-old man who had been treated with decompression and placement of a coflex device (Paradigm Spine) at L3-L4 and L4-L5. Preoperative imaging clearly demonstrated fluid in the facet joints without cysts. He underwent standard surgical treatment, but developed symptomatic facet joint cysts at 4 months postoperatively. The patient was treated with a revision decompression and replacement of the devices; there were no issues at the 32-month follow-up. CONCLUSION: While the coflex device has possible long-term biomechanical advantages, vigilance with adherence to appropriate decompression surgical technique is necessary.