The February 2024 Spine Roundup³⁶⁰ looks at: Surgeon assessment of bone – any good?; Robotics reduces radiation exposure in some spinal surgery; Interbody fusion cage versus anterior lumbar interbody fusion with posterior instrumentation; Is robotic-assisted pedicle screw placement an answer to the learning curve?; Acute non-traumatic spinal subarachnoid haematomas: a report of five cases and a systematic review of the literature; Is L4-L5 lateral interbody fusion safe and effective?

Aims

To determine the effectiveness of prone traction radiographs in predicting postoperative slip distance, slip angle, changes in disc height, and lordosis after surgery for degenerative spondylolisthesis of the lumbar spine.

Obesity is an increasing public health concern associated with increased perioperative complications and expense in lumbar spine fusions. While open and mini-open fusions such as transforaminal lumbar interbody fusion (TLIF) and minimally invasive TLIF (MIS-TLIF) are more challenging in obese patients, new MIS procedures like oblique lateral lumbar interbody fusion (OLLIF) may improve perioperative outcomes in obese patients relative to TLIF and MIS-TLIF. The purpose of this study is to determine the effects of obesity on perioperative outcomes in OLLIF, MIS-TLIF, and TLIF. This is a retrospective cohort study. We included patients who underwent OLLIF, MIS-TLIF, or TLIF on three or fewer spinal levels at a single Minnesota hospital after conservative therapy had failed. Indications included in this study were degenerative disc disease, spondylolisthesis, spondylosis, herniation, stenosis, and scoliosis. We measured demographic information, body mass index (BMI), surgery time, blood loss, and hospital stay. We performed summary statistics to compare perioperative outcomes in MIS-TLIF, OLLIF, and TLIF. We performed multivariate regression to determine the effects of BMI on perioperative outcomes controlling for demographics and number of levels on which surgeries were operated. OLLIF significantly reduces surgery time, blood loss, and hospital stay compared to MIS-TLIF, and TLIF for all levels. MIS-TLIF and TLIF do not differ significantly except for a slight reduction in hospital stay for two-level procedures. On multivariate analysis, a one-point increase in BMI increased surgery time by 0.56 ± 0.47 minutes (p = 0.24) in the OLLIF group, by 2.8 ± 1.43 minutes (p = 0.06) in the MIS-TLIF group, and by 1.7 ± 0.43 minutes (p < 0.001) in the TLIF group. BMI has positive effects on blood loss for TLIF (p < 0.001) but not for OLLIF (p = 0.68) or MIS-TLIF (p = 0.67). BMI does not have significant effects on length of hospital stay for any procedure. Obesity is associated with increased surgery time and blood loss in TLIF and with increased surgery time in MIS-TLIF. Increased surgery time may be associated with increased perioperative complications and cost. In OLLIF, BMI does not affect perioperative outcomes. Therefore, OLLIF may reduce the disparity in outcomes and cost between obese and non-obese patients

Aims. We compared the clinical and radiological outcomes of using a polyetheretherketone cage with (TiPEEK) and without a titanium coating (PEEK) for instrumented transforaminal lumbar interbody fusion (TLIF). Materials and Methods. We conducted a randomised clinical pilot trial of 40 patients who were scheduled to undergo a TLIF procedure at one or two levels between L2 and L5. The Oswestry disability index (ODI), EuroQoL-5D, and back and leg pain were determined pre-operatively, and at three, six, and 12 months post-operatively. Fusion rates were assessed by thin slice CT at three months and by functional radiography at 12 months. Results. At final follow-up, one patient in each group had been lost to follow-up. Two patients in each of the PEEK and TiPEEK groups were revised for pseudarthrosis (p = 1.00). The rate of complete or partial fusion at three months was 91.7% in both groups. Overall, there were no significant differences in ODI or in radiological outcomes between the groups. Conclusion. Favourable results with identical clinical outcomes and a high rate of fusion was seen in both groups. The titanium coating appears to have no negative effects on outcome or safety in the short term. A future study to determine the effect of titanium coating is warranted. Cite this article: Bone Joint J 2017;99-B:1366–72

Aims

Minimally invasive transforaminal lumbar interbody fusion (MITLIF) has been well validated in overweight and obese patients who are consequently subject to a higher radiation exposure. This prospective multicentre study aimed to investigate the efficacy of a novel lumbar localisation system for MITLIF in overweight patients.

Transforaminal lumbar interbody fusion (TLIF) using an implanted cage is the gold standard surgical treatment for disc diseases such as disc collapse and spinal cord compression, when more conservative medical therapy fails. Titanium (Ti) alloys are widely used implant materials due to their superior biocompatibility and corrosion resistance. A new Ti-6Al-4V TLIF cage concept featuring an I-beam cross-section was recently proposed, with the intent to allow bone graft to be introduced secondary to cage implantation. In designing this cage, we desire a clear pathway for bone graft to be injected into the implant, and perfused into the surrounding intervertebral space as much as possible. Therefore, we have employed shape optimization to maximize this pathway, subject to maintaining stresses below the thresholds for fatigue or yielding. The TLIF I-beam cage (Fig. 1(a)) with an irregular shape was parametrically designed considering a lumbar lordotic angle of 10°, and an insertion angle of 45° through the left or right Kambin's triangles with respect to the sagittal plane. The overall cage dimensions of 30 mm in length, 11 mm in width and 13 mm in height were chosen based on the dimensions of other commercially available cages. The lengths (la, lp) and widths (wa, wp) of the anterior and posterior beams determine the sizes of the cage's middle and posterior windows for bone graft injection and perfusion, so they were considered as the design variables for shape optimization. Five dynamic tests (extension/flexion bending, lateral bending, torsion, compression and shear compression, as shown in Fig. 2(b)) for assessing long term cage durability (10. 7. cycles), as described in ASTM F2077, were simulated in ANSYS 15.0. The multiaxial stress state in the cage was converted to an equivalent uniaxial stress state using the Manson-Mcknight approach, in order to test the cage based on uniaxial fatigue testing data of Ti-6Al-4V. A fatigue factor (K) and a critical stress (σcr) was introduced by slightly modifying Goodman's equation and von Mises yield criterion, such that a cage design within the safety design region on a Haigh diagram (Fig. 2) must satisfy K ≤ 1 and σcr ≤ SY = 875 MPa (Ti-6Al-4V yield strength) simultaneously. After shape optimization, a final design with la = 2.30 mm, lp = 4.33 mm, wa = 1.20 mm, wp = 2.50 mm, was converged upon, which maximized the sizes of the cage's windows, as well as satisfying the fatigue and yield strength requirements. In terms of the strength of the optimal cage design, the fatigue factor (K) under dynamic torsion approaches 1 and the critical stress (σcr) under dynamic lateral bending approaches the yield strength (SY = 875 MPa), indicating that these two loading scenarios are the most dangerous (Table 1). Future work should further validate whether or not the resulting cage design has reached the true global optimum in the feasible design space. Experimental validation of the candidate TLIF I-beam cage design will be a future focus. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Study design. Prospective randomized study. Objective. Primary aim of this study was to compare clinical and radiological results of transforaminal lumbar interbody fusion (TLIF) with posterolateral (interlaminar) instrumented lumbar fusion (PLF) in adult low grade (Meyerding 1 & 2) spondylolisthesis patients. Background data. Theoretically, TLIF has better radiological result than PLF in spondylolisthesis in most of the studies. Method. 24 patients of low grade adult spondylolisthesis were randomly allocated to one of the two groups: group 1- PLF and group 2-TLIF. Study period was between August 2010 to March 2013. All patients were operated by a single surgeon (CN). Posterior decompression was performed in all patients. Average follow up period was 18.4 months. Quality of life was accessed with Visual analogue scale and Oswestry Low Back Pain Disability Index. Fusion was assessed radiologically by CT scan and X-ray. Result. Though fusion was significantly better in TLIF group, clinical outcome including relief of back pain and neurogenic claudication were better in PLF group. Rate of complication was also lower in PLF group. Conclusion. Considering the low complication rate and similar or better clinical results, posterolateral instrumented lumbar fusion is the better option in low grade adult spondylolisthesis

The August 2013 Spine Roundup³⁶⁰ looks at: SPECT CT and facet joints; a difficult conversation: scoliosis and complications; time for a paradigm shift? complications under the microscope; minor trauma and cervical injury: a predictable phenomenon?; more costly all round: incentivising more complex operations?; minimally invasive surgery = minimal scarring; and symptomatic lumbar spine stenosis.

Purpose of the study: Revision surgery for scoliosis in adults is a technical challenge. Indications include flat back, non-union, and syndromes adjacent to the instrumentation The purpose of this work was to evaluate the pertinence of the transforaminal lumbar interbody fusion (TLIF) method for revision surgery for scoliosis in adults. Material and methods: In our spinal surgery unit, 23 patients underwent revision surgery for thoracolumbar and lumbar scoliosis. A unique posterior approach was used. The TLIF was performed systematically at the lumbosacral level, at the non-union when it was present, and at the level of the Smith-Petersen osteotomies, as well as the levels above and below a transpedicular osteotomy. Seventeen patients presented flat back, ten non-union, five degenerative disease distal to the instrumentation and one degeneration proximal to the instrumentation. Nine patients had several indications for surgical revision. Five transpedicular osteotomies were performed in five patients. Results: Mean follow-up was 30 months (range 18–48). On average 2.3 levels (range 1–4) were involved in the TLIF. The fusion was extended to the sacrum in 22 patients. The mean operative time was 5h50m (range 3–8 hours). Mean blood loss was 2100ml (400–4500). Postoperative lumbar lordosis (L1S1) was 53.5°, giving an improvement of 23° copared with the preoperative lordosis. Among the postoperative complications, there was one neurological complications which recovered partially at last follow-up one case of deep infection of the operative site which require partial removal of the implants and one case of recurrent non-union. There was no loss of correction in the frontal or sagittal planes with the exception of one patient who developed an infection. None of the patients in the series required complementary anterior surgery. Conclusion: For revision surgery of scoliosis in the adult, a circumferential arthrodeis is needed to maintain the fusion. The TLIF method has the advantage of allowing intersomatic fusion via the posterior approach alone without opening the spinal canal. We consider that the TLIF technique is an alternative to two-phase procedures for revision surgery for scoliosis in adults. This method has given a good percentage of fusion in our series with little loss of correction

In a prospective observational study we compared the two-year outcome of lumbar fusion by a simple technique using translaminar screws (n = 57) with a more extensive method using transforaminal lumbar interbody fusion and pedicular screw fixation (n = 63) in consecutive patients with degenerative disease of the lumbar spine. Outcome was assessed using the validated multidimensional Core Outcome Measures Index. Blood loss and operating time were significantly lower in the translaminar screw group (p < 0.01). The complication rates were similar in each group (2% to 4%). In all, 91% of the patients returned their questionnaire at two-years. The groups did not differ in Core Outcome Measures Index score reduction, 3.6 (sd 2.5) (translaminar screws) vs 4.0 (sd 2.8) (transforaminal lumbar interbody fusion) (p = 0.39); ‘good’ global outcomes, 78% (translaminar screws) vs 78% (transforaminal lumbar interbody fusion) (p = 0.99) or satisfaction with treatment, 82% (translaminar screws) vs 86% (transforaminal lumbar interbody fusion) (p = 0.52).

The two fusion techniques differed markedly in their extent and the cost of the implants, but were associated with almost identical patient-orientated outcomes.

Extensive three-point stabilisation is not always required to achieve satisfactory patient-orientated results at two years.

The purpose of the study was to determine the effectiveness of rhBMP-2 when applied to an absorbable collagen sponge for interbody fusion with allograft spacers. Seventy-seven consecutive patients requiring inter-body fusion with one hundred and eighteen levels were included in the study. In thirty-six patients cervical or lumbar interbody fusions were performed using allograft and rhBMP-2. In the remaing allograft was used with demineralised bone matrix. In patients undergoing anterior cervical decompression and fusion (ALIF) machined allograft spacers were supplemented with anterior locking plates. In those scheduled for anterior lumbar inter-body fusion (ALIF) or transforaminal lumbar interbody fusion (TLIF), machined allograft spacers were supplemented with posterior pedicle screw constructs. There were no stand alone ALIF procedures. All patients undergoing surgery were assessed preoperatively and at two weeks, six weeks, three, six, twelve, twenty-four months following surgery.Their Oswestry disability index (ODI) questionaires, Visual analogue scale (VAS) scores and a pain diagram were recorded. Radiographic measurements were made on the electronic public access computer system (EPACS). All patients with allograft plus rhBMP-2 showed radiographic evidence of fusion by six months following surgery. The allograft with demineralised bone matrix group took considerably longer to achieve the same radiographic end plate appearance. Subsidence was obvious on radiographs in greater than 50% of cases with allograft and rhBMP-2 at three months. It was noted to occur between six weeks and three months and there was no significant subsidence after six months. This was statistically significant with a p< 0.0001 (fisher exact test). The average subsidence for the entire rhBMP-2 group at twelve months was 16.5%(SE 2.5% and range 0–58%) and for the allograft and bone matrix group was 4.6%(SE.74% range 0–15%)with a p< 0.0001 (independant t test). Although high rates of fusion can be accomplished with allograft and rhBMP-2 (100%), significant subsidence occurs in greater than 50% of lumbar spine cases and 30% of cervical spine cases. This is possibly a result of early bone turnover with loss of structural support of the allograft spacer and end plate resorption

The purpose of this study was to investigate the efficacy and fusion rates of a unilateral pedicle screw construct supplemented with a translaminar screw in transforaminal lumbar interbody fusion (TLIF). The construct was used with an aim of providing suitable spine stiffness with minimal implant load for spinal fusion. Nineteen consecutive patients who underwent single level TLIF were included in the study. All patients had posterior spinal instrumentation using a unilateral pedicle screw construct with a contralateral translaminar screw. Patients were assessed preoperatively and at two, six, twelve and twenty-four weeks following surgery and at the end of one and two years. At every visit Oswestry disability index score,Visual analogue scale for pain and a pain diagram were recorded. A radiographic exam was also conducted and CT scan was done if there was concern about fusion. The average follow up was twenty-four months. There were twelve males and seven females with an average age of forty-eight years. All patients went on to clinical and radiographic union. Sixteen of nineteen patients had significant clinical improvement on VAS for pain, Oswestry scores and pain medication. Three patients had recurrence of radicular pain on the side of the TLIF leading to reexploration. In all three patients solid fusion was observed but scar tissue was evident and symptoms resolved following redecompression of the foramen. The biomechanical competence of a construct is evidenced by successful fusion. With the advent of minimally invasive techniques to achieve spinal fusion the goal is to use minimal instrumentation without compromising on the final stiffness of the spine. The construct of unilateral pedicle screws supplemented with a trans-laminar screw led to fusion in all our cases. It requires lesser soft tissue dissection and the posterior implants are 56% cheaper

Introduction Circumferential fusion is becoming increasingly popular and has been advocated by many authors to improve the fusion rates and clinical outcomes of the degenerative lumbosacral spine. Anterior lumbar interbody fusion (ALIF) with posterolateral fusion does provide direct access to the disc via a separate incision/ approach but has inherent neurovascular risks. Posterior lumbar interbody fusion (PLIF) with posterolateral fusion mandates bilateral exposure with significant retraction of neural elements with higher incidence of postoperative radiculitis. PLIF also reduces surface area for fusion and disrupts the posterior tension band. TLIF allows for a circumferential fusion through a single posterior incision with only slight retraction of the thecal sac and nerve roots, with much less morbidity and costs as compared to traditional PLIF and ALIF techniques. To our knowledge, there are no studies that report radiographic and clinical results of using recombinant human bone morphogenic protein (rhBMP-2) and allograft in a TLIF setting. The purpose of this study was to assess clinical & radiographic outcomes of patients treated with one or two level instrumented transforaminal lumbar interbody fusions (TLIF) performed with allograft and rh-BMP2 for treatment of symptomatic spondylolisthesis or degenerative disc disease. Methods During a consecutive 13 month period, 77 patients underwent TLIF procedures utilizing rhBMP-2 by one spine surgeon for lumbosacral degenerative and deformity conditions with simultaneous posterolateral fusions with allograft. Pedicle screw instrumentation (Monarch, DePuy Spine) provided distraction and a carbon-fiber curvilinear cage (Leopard, Depuy Spine) packed with rhBMP-2 (Large II Kit, total graft volume 8ml onto 77.4 sq. cm collagen sponge; Infuse: Medtronic Sofamor Danek) was placed into the disk space after hemifacetectomy and discectomy. The patients were followed at two weeks and three, six, 12 and 24 months after surgery patients were followed with several functional parameters such as the visual analog scale (VAS), SF-36 and Oswestry Disability Index (ODI) questionnaires. Fusion was assessed by static and dynamic radiographs at 6, 12, and 24 months as well as CT scans at 24 months. Results 71 patients were available for follow-up (92%) evaluation (mean 16 months; range 6–24 months). At 24 months, 85 percent and 81 percent of patients had improvement over preoperative ODI and SF-36 measures respectively. At 24 months, 70% of patients had good to excellent outcomes by both ODI and SF-36. We achieved 94% fusion rate with only four pseudarthroses. There was one wound infection treated with hardware removal and intravenous antibiotics. One patient had excessive bone growth into the foramen, necessitating surgical decompression with subsequent excellent clinical outcome. Ten patients had paresthesias on the side of the TLIF, all of which resolved by three weeks. There were no permanent neurologic deficits. Discussion The use of rhBMP-2 inside the cage, in combination with posterolateral allograft, can provide a high fusion rate and good clinical outcomes in a TLIF setting. The morbidity associated with iliac crest bone graft is avoided, with fusion rates approaching that of a true anterior/posterior circumferential fusion. Complications were few, with no significant neurologic sequelae from the placement of a structural graft into the anterior column through a posterior approach. Overgrowth of bone into the neural foramen, likely related to the residue of rhBMP-2 at the TLIF entry site, can occur. Care must be taken to place the TLIF cage device and the contained rhBMP-2 into the anterior half of the disk space to minimize the risk of this complication

Purpose: Circumferential arthrodesis of the lumbar spine is necessary in certain selected situations (lumbar stenosis with instability and preserved disc height or spondylolisthesis). Posterior lumbar interbody fusion (PLIF) raises the risk of significant bleeding and fibrosis around the roots as well as neurological complications. Transforaminal lumbar interbody fusion (TLIF) can avoid excessive bleeding and root displacement. The cages are inserted via a unilateral approach. Material and methods: This prospective single-centre study included twenty patients (nine men and eleven women), mean age 49 years. Indications for lumbar surgery were degenerative spondylolisthesis in nine patients and discal lumbar pain with foraminal stenosis in five. The clinical status was assessed with the Oswestry score, SF-36 and a visual analogue scale (VAS). Radiological assessment was based on inter-body fusion, segmentary lordosis, and lumbopelvic parameters. TLIF was associated with a posterior approach for insertion of titanium pedicular screws (CDH, Medtronic Sofamor Danek). Temporary unilateral distraction opened the foramen. Unilateral arthrectomy enabled a lateral approach to the disc without involving the roots and avoiding any movement of the dural sac. The disc was resected and the body endplates were prepared before introducing two cages (pyramesh) filled with macroporous ceramic granules (BCP) mixed with autologous bone marrow. Installation to two contourned rods enabled segmentary compression to stabilise the cages in association with posterolateral fusion. Results: Mean operative time was three hours. Mean blood loss was 400 ml. The patients were verticalised on day three without a corset. Mean follow-up was six months with retrospective evaluation of the Oswestry score, SF-36, and VAS. Postoperative pain resolved rapidly. Two patients developed transient incomplete L5 deficit. Bony bridges around the cases and posterolaterally were identified on the six-month x-rays. Spine view confirmed the quality of the fusion and lumbopelvic parameters revealed restoration of segmentary lordosis. Conclusion: The unilateral approach for TLIF is a reliable technique which does not compromise the roots. It enables very reliable primary stability and recovery of local segmentary lordosis. We are developing a minimally invasive percutaneous technique for this procedure