Spinal Fusion

-BACKGROUND: Frailty refers to a state of weakness that can arise due to age
or illnesses, and frailty predisposes individuals to several adverse health out
comes. This has been postulated to prognosticate the outcome of various sur
geries, including surgeries for various spine conditions; however, no meta
analysis has validated this finding.-METHODS: We conducted a systematic review and meta-analysis to inves
tigate the prognostic utility of frailty for the outcome of spine surgeries. We
performed a systematic search of the PubMed, EMBASE, and SCOPUS databases
for studies investigating the ability of frailty to predict the outcome of spine
surgeries. We analyzed the effect of high frailty using the 5-item Modified Frailty
Index on the outcomes (extended length of stay, readmission, postoperative
complications, in-hospital mortality, reoperation, and nonroutine discharge) of
spine surgeries.-RESULTS: Meta-analysis of the information provided in the 11 studies
included a sample size of 89,137; all studies used the 5-item Modified Frailty
Index ‡2 as their cutoff for high frailty, and most studies were performed in the
United States based on the American College of Surgeons National Surgical
Quality Improvement Program database. The outcomes of our analysis were
extended hospital length of stay (effect size 1.64; 95% confidence interval [CI]:
1.49, 1.79), postoperative complications (effect size 1.49; 95% CI: 1.10, 1.88),
readmission (effect size 1.69; 95% CI: 1.40, 1.99), nonroutine discharge (effect size
2.16; 95% CI: 1.80, 2.51), postoperative in-hospital mortality (effect size 2.11; 95%
CI: 1.25, 2.96), and reoperation (effect size 1.32; 95% CI: 1.19, 1.45).-CONCLUSIONS: This study revealed that high frailty according to the modi
fied 5-Item Frailty Index is correlated with an increased risk of readmission,
extended length of hospital stay, postoperative complications, nonroutine
discharge, postoperative in-hospital mortality, and reoperation following spine
surgeries for any pathology of the spine.

OBJETIVO: Relatar a experiência inicial de um serviço de referência em cirurgia da coluna em São Paulo, Brasil com a técnica de fusão intersomática lombar transforaminal (TLIF) nas suas mais variadas indicações. MÉTODOS: Avaliamos retrospectivamente os dados gravados em prontuário de 25 pacientes que foram submetidos à cirurgia com a técnica de TLIF no ano de 2011. Um paciente foi excluído porque não consideramos que a TLIF foi a principal técnica empregada. As indicações incluíram nove casos de hérnia de disco lombar, sete espondilolisteses, quatro cirurgias de revisão, sendo duas por pseudoartrose e duas por lombalgias e, finalmente, quatro pacientes com estenose espinhal lombar. RESULTADOS: Todos os pacientes referiram melhora da dor e/ou claudicação neurológica em comparação com o estado pré-operatório. Apenas cinco pacientes continuaram usando alguma medicação analgésica. Cinco pacientes apresentaram alguma complicação, mas somente duas delas estão relacionadas diretamente com ...

Surgical treatment of cervical spondylotic myelopathy (CSM) aims to prevent or delay the progression of the disease. Many patients are diagnosed in advanced stages of the disease, presenting severe functional disability and extensive radiologic changes, which suggests clinical irreversibility. There are doubts about the real benefit of surgery in patients who are seriously ill, bedridden or in a wheelchair. The objective of the study is to evaluate the effects of surgical treatment in the clinical outcomes of patients severely affected by CSM. We analyzed patients with CSM who received an operation at a single institution between 1996 and 2008. Cases with a preoperative Nurick score equal to 5 were studied. We describe postoperative clinical improvement and compare the demographics and clinical data between the patients who improved and those who had no improvement. Radiological findings were also analyzed. We evaluated 55 patients operated on. Nine presented with preoperative Nurick score of 5 (16.3%). The mean age was 69.77 ± 6.6 years (95% CI 64.65-79.90). The mean follow-up was 53.44 ± 35.09 months ). Six patients (66.6%) achieved functional improvement when assessed by the Nurick scale, regaining the ability to walk. All patients improved on the JOAm scale, except one. The mean preoperative Nurick score was 5, while the mean postoperative Nurick score was 4.11 ± 0.92 (95% CI 3.39-4.82) (Wilcoxon p = 0.027). The mean preoperative JOAm score was 6.4, and postoperative was 9.88 ± 2.31 (CI 95% 8.10-11.66) (Wilcoxon p = 0.011). All spinal cords presented high-intensity signal on T2-weighted images. There was no correlation between the number of spinal cord high-intensity signal levels and clinical improvement. Three out of seven patients (whose image was adequate for analysis) had evident spinal cord atrophy, and two of them did not improve clinically. In the whole sample of patients, the mean length of disease for those who improved was 9.25 ± 7.31 months (95% CI 1.56-16.93), and for those who did not improve was 38.00 ± 19.28 months (95% CI 9.91-85.91) (Mann-Whitney p = 0.02). In conclusion, two-thirds of patients with CSM Nurick scores of 5 who were either bedridden or in wheelchairs at the time of diagnosis improved at least one degree on the Nurick scale after surgical treatment, thus returning to walking. The JOAm scale was more sensitive to clinical changes than the Nurick scale. Patients with longer lengths of disease had worse outcomes.

BACKGROUND CONTEXT: Wound dehiscence and surgical site infections (SSIs) can have a profound impact on patients as they often require hospital readmission, additional surgical interventions, lengthy intravenous antibiotic administration, and delayed rehabilitation. Negative pressure wound therapy (NPWT) exposes the wound site to negative pressure, resulting in the improvement of blood supply, removal of excess fluid, and stimulation of cellular proliferation of granulation tissue. PURPOSE: To assess the incidence of wound infection and dehiscence in patients undergoing long-segment thoracolumbar fusion before and after the routine use of NPWT. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: One hundred sixty patients undergoing long-segment thoracolumbar spine fusions were included in this study. OUTCOME MEASURES: Postoperative incidence of wound infection and dehiscence. METHODS: All adult patients undergoing thoracolumbar fusion for spinal deformity over a 6-year period at Duke University Medical Center by the senior author (CB) were included in this study. In 2012, a categorical change was made by the senior author (CB) that included the postoperative routine use of incisional NPWT devices after primary wound closure in all long-segment spine fusions. Before 2012, NPWT was not used. After primary wound closure, a negative pressure device is contoured to the size of the incision and placed over the incision site for 3 postoperative days. We retrospectively review the first 46 cases in which NPWT was used and compared them with the immediately preceding 114 cases to assess the incidence of wound infection and dehiscence. RESULTS: One hundred sixty (NPWT: 46 cases, non-NPWT: 114 cases) long-segment thoracolumbar spine fusions were performed for deformity correction. Baseline characteristics were similar between both cohorts. Compared with the non-NPWT cohort, a 50% decrease in the incidence of wound dehiscence was observed in the NPWT patient cohort (6.38% vs. 12.28%, p5.02). Similarly, compared with the non-NPWT cohort, the incidence of postoperative SSIs was significantly decreased in the NPWT cohort (10.63% vs. 14.91%, p5.04). CONCLUSIONS: Routine use of incisional NPWT was associated with a significant reduction in the incidence of postoperative wound infection and dehiscence.

Background Calcium phosphate materials have been employed clinically as bone void fillers for several decades. These materials are most often provided in the form of small, porous granules that can be packed to fill the wide variety of size and shape of bony defects encountered. ReBOSSIS-85 (RB-85) is a synthetic bioresorbable bone void filler for the repair of bone defects with handling characteristics of glass wool-like (or cotton ball-like). The objective of this study is to evaluate the in vivo performance of RB-85 (test material), compared to a commercially available bone void filler, Mastergraft Putty (predicate material), when combined with bone marrow aspirate and iliac crest autograft, in an established posterolateral spine fusion rabbit model. Methods One hundred fifty skeletally mature rabbits had a single level posterolateral fusion performed. Rabbits were implanted with iliac crest bone graft (ICBG), Mastergraft Putty™ plus ICBG, or one of 4 masses of ReBOSSIS-85 (0.2, ...

Randomized, controlled study in a laboratory setting. Blinded observations/assessment of study outcomes. The purpose of this study is to determine the performance characteristics of a novel silicate-substituted hydroxyapatite bone graft substitute (BGS), SiCaP EP (Baxter Healthcare/ ApaTech, Elstree, UK), in a stand-alone mode, a stand-alone with bone marrow aspirate (BMA) mode, and an extender mode with iliac crest autograft (ICBG) in a rabbit posterolateral spine fusion model. The investigational BGS is compared to a standard iliac crest autograft (ICBG) control. The rabbit posterolateral fusion model is an established environment for testing of fusion efficacy. It offers the opportunity to obtain radiographic, histological, and biomechanical data on novel bone graft substitutes. One hundred and twenty rabbits were entered into the study with 116 used for analysis. Bilateral posterolateral lumbar intertransverse fusions were performed at L5-L6. The lateral two thirds of the transv...

The drawbacks of iliac crest autograft as graft material for spine fusion are well reported. Despite continued modifications to improve bone healing capacity, the efficacy of synthetic graft materials as stand-alone replacements remains uncertain. The rabbit posterolateral fusion model is an established environment for testing of fusion concepts. It offers the opportunity to obtain radiographic, biomechanical and histological data on novel fusion materials. The objective of this study was to compare the spine fusion capability of two synthetic bone graft products in an established rabbit posterolateral spine fusion (PLF) model: Signafuse® Bioactive Bone Graft Putty and Actifuse® ABX. Bilateral intertransverse spine fusion was performed at the L5-L6 transverse processes (TPs) of New Zealand White rabbits using either Signafuse or Actifuse ABX as the bone graft material. Bone remodeling and spine fusion were assessed at 6 and 12 weeks using radiographic, biomechanical and histological...

Kyphoscoliosis is a complex spinal deformity with profound musculoskeletal, neurological, and cardiopulmonary implications. Management requires a patient-specific, multidisciplinary approach, integrating both conservative and surgical strategies. Conservative management encompasses observation, pain control, bracing, physical therapy, and cardiopulmonary optimization, particularly with noninvasive positive pressure ventilation for patients at risk of respiratory failure. These strategies aim to stabilize the deformity, relieve symptoms, and maintain function. Surgical management is reserved for progressive curves exceeding 45-50 degrees, refractory pain, neurological compromise, or significant cosmetic concerns, and includes spinal fusion, osteotomies, vertebral column resection, and growth-friendly techniques in children. Postoperative care emphasizes respiratory monitoring, pain control, and the prevention of surgical complications such as pseudoarthrosis and hardware failure. The ultimate goal is to improve quality of life while minimizing morbidity and mortality. Timely recognition of progression, vigilant follow-up, and multidisciplinary collaboration remain essential to optimize outcomes in this lifelong condition.

Back and neck pain related to disc problems is a common concern, with a considerable number of patients seeking medical care for conditions such as herniated or bulging discs. For some, persistent pain affects daily activities and quality of life despite medication, physiotherapy or other conservative measures. In these cases, minimally invasive procedures such as nucleoplasty may be considered. What Is Nucleoplasty and How Does It Work? Nucleoplasty, also known as percutaneous disc decompression, is a minimally invasive procedure designed to treat pain caused by bulging or herniated spinal discs. By removing small amounts of disc material from the centre of the disc, the procedure reduces internal pressure and allows the bulging disc to retract away from compressed nerves. The procedure takes about 20 to 60 minutes and is typically performed on an outpatient basis. Using fluoroscopic (real-time X-ray) guidance, the doctor carefully inserts a thin needle through the skin into the affected disc. A specialised probe is then passed through the needle to precisely remove tissue in a controlled manner. The entire process is done under local anaesthesia with light sedation, keeping you comfortable and alert enough to provide feedback to ensure accurate targeting.

Bone fusion may be achieved using one or more of three surgical strategies: in situ, onlay, or interbody fusion. In situ fusions are used when native bone is allowed to come in contact with other native bone that was previously prevented from doing so because of intervening soft tissue. A common clinical example is the denuding of facet cartilage performed in conjunction with placing a lateral mass plate system in the cervical spine. Onlay fusion techniques rely on a decorticated graft bed and the subsequent application of cortical and cancellous autograft. Interbody implants provide the spine with the ability to bear an axial load; they function optimally when placed along the neutral axis and thus produce little, if any, significant bending moment. Interbody implants may be comprised of bone, nonbone materials such as acrylic, or a combination of both, such as interbody cages. All three methods may be used alone or in combination with other implants that can be applied through anterior and/or posterior applications. The application of interbody implants has more complex biomechanical implications than the other two implants and thus is the focus of this discussion. Interbody implants benefit from the compression-related augmentation of the bone healing-enhancing forces, as predicted by the Wolff law. The theoretical, as well as practical, biomechanical factors that influence bone fusion are presented here. First, we review of the concept of using bone as an implant material. Second, with the attendant biomechanical nuances of the different regions of the spine, we discuss regionspecific strategies. Third, we review the intraoperative techniques that will improve the chance of achieving a successful arthrodesis. Theoretically, there is an optimal distribution of load between a spinal implant and a bone graft. Such ideal balance provides stability, yet allows the graft to "see" the necessary compressive forces for healing, as delineated in the Wolff law. Seventy percent of the load should optimally be applied through the bone graft in both the thoracic and lumbar spine (BC Cheng, CSRS, 1997). When a disproportionate amount of the load is borne by the implant, the chance of achieving a solid arthrodesis diminishes. Stress shielding is defined as an implant induced reduction of bone healing enhancing stresses and loads to such a degree that stress reduction osteoporosis, or nonunion, may result. In addition to the most common culprit-spinal instrumentation-inactivity, such as bedrest, and spinal bracing may also play a role. In a head-to-head comparison, one group of authors reviewed their clinical experience with four anterior cervical strategies: 1) strut graft combined with halo brace; 2) anterior cervical plate combined with strut graft; 3) anterior strut graft combined with posterior instrumentation and fusion; and 4) anterior strut graft combined with a kickplate; the pseudarthrosis rates were 20%, 40%, 0%, and 7%, respectively (ES Doh, CSRS, 1998). Several conclusions may be drawn from these findings. Fusion in which no instrumentation was used in this series was relatively efficacious. This has been borne out in other studies as well (A Hildibrand, NASS, 1997). 10, The stress shielding of the rigid plate most likely contributed to the high pseudarthrosis rate. The addition of a posterior fusion appears to prevent settling while promoting fusion. Neurosurg Focus 10 (4):Article 2, 2001, Click here to return to Table

Study Design: An in-vivo experiment. Objectives: To evaluate the feasibility of achieving bone formation by percutaneous gene delivery, with plasmid DNA encoding BMP-7(OP-1). Summary of Literature Review: Currently, the preferred method for posterolateral spinal fusion involves decortication of the transverse process, followed by a graft of autogenous bone harvested from the iliac crest. Unfortunately, this procedure suffers from significant morbidity, including blood loss, infection and persistent pain at the harvest site. Material and Methods: 24 Sprague-Dawley rats, weighing approximately 250～300 g, were used. The percutaneous injection was attempted above both the L5 transverse processes. The animals were divided into three groups, according to the injection materials: 1) OP-1 gene/collagen, 2) recombinant OP-1 protein/collagen and 3) control of PBS/collagen. At 2 and 4 weeks post-injection, the animals were sacrificed. The gross, radiological and histological findings were analyzed. No bone was detected grossly by manual palpation or radiography in the groups receiving OP-1 gene/collagen at either time point. The histological findings revealed the initiation of endochondral bone formation within the paraspinal muscle, directly above the L5 transverse process. In the rhOP-1 protein/collagen groups, the gross, radiological and histological findings revealed extensive cartilage and bone formation at both 2 and 4 weeks. In conclusion, the authors confirmed the feasibility of achieving bone formation by percutaneous gene delivery, with plasmid DNA encoding BMP-7(OP-1).

Cette étude a permis de répondre aux objectifs et problématiques définis :

Les effets de la méthode Schroth sur la réduction des douleurs et des symptômes associés
à la scoliose chez les patients de Risser 5 : Les résultats montrent une réduction significative
de la douleur au repos et en dynamique, ainsi qu'une amélioration des scores de qualité de vie
(SRS-22) et d'image corporelle (TAPS). Ces améliorations attestent de l'efficacité de la méthode
Schroth dans la gestion des symptômes de la scoliose.

L'évaluation de l'efficacité de la méthode Schroth dans le traitement de la scoliose
idiopathique : La méthode Schroth a démontré des bénéfices notables, y compris une
diminution de la douleur et des gains en flexibilité cervicale et lombaire. Les ajustements dans
les activités de la vie quotidienne (AVQ) ont joué un rôle crucial, renforçant l'efficacité de
l'intervention.

L'influence de la modification des AVQ selon la méthode de Schroth sur la progression
de la courbure scoliotique et la qualité de vie des patients : L'intégration des principes de la
méthode avec des modifications des AVQ a conduit à une gestion améliorée de la scoliose. Les
résultats suggèrent que ces changements ont contribué à une meilleure qualité de vie et une
gestion plus efficace de la courbure scoliotique.

En résumé, cette étude confirme que la méthode Schroth, lorsqu'elle est appliquée en
conjonction avec des ajustements adaptés des AVQ, est efficace pour traiter la scoliose. Les
améliorations observées dans les scores de douleur, les mesures de flexibilité et la qualité de
vie des patientes soulignent les avantages de cette approche intégrée. Ces conclusions s'alignent
avec les résultats rapportés par d'autres centres utilisant la méthode Schroth et les travaux de
Katarina Schroth, renforçant la validité de cette approche dans le traitement de la scoliose
idiopathique.

Proteus syndrome is a very rare condition with less than 100 confirmed cases reported worldwide. We report a case of Proteus syndrome in a two-year-old male who has hemophilia A comorbidity. A two-year-old male patient was admitted with the chief complaint of severe bleeding in mouth cavity after trauma for two weeks. At admission he was found to have petechiae on buccal mucosa and fecal discoloration due to GI bleeding. We noted multiple abnormalities in his musculoskeletal system and skin. He had lymph edema in left leg, hemihypertrophy, macrodactyly in both foots and macrocephaly. With the history of severe bleeding and recurrent blood product transfusion, we suspected a hemorrhagic disorder. The reduced level of Factor VIII activity confirmed the diagnosis of hemophilia A. Considering patient's various musculoskeletal abnormalities according to the diagnostic criteria and after ruling out similar disorders the diagnosis of Proteus syndrome was established. Because of the var...

Objective: To evaluate preoperative, postoperative, and follow-up of spinal and pelvic parameters using EOS 3D imaging in adolescent idiopathic scoliosis (AIS) patients who underwent simultaneous translation on two rods (ST2R) technique for corrective posterior spinal surgery.
Methods: Five patients had surgical correction of Lenke type 1 or 2 AIS using the ST2R technique. The preoperative average Cobb angle was 72.4° ± 19.4. Low-dose standing biplanar radiographs were obtained to evaluate several spinal and pelvic parameters preoperatively (five patients), immediately postoperatively (four patients), and at follow-up (four patients). Three-dimensional reconstructions were performed (a total of 13 reconstructions).
Results: The mean number of levels fused was 11.2° ± 2.0. The number of pedicle screws used for constructs averaged 19.2° ± 3.06 (1.75 density screw per vertebra). The Cobb angle values were significantly changed by the operation (75° ± 21 to 28° ± 7, p = 0.009), but no other parameters were altered. The maximal apical axial change at the junctional region was 32.8° (absolute value), and the minimal apical axial change at the apical region was 4.8° (absolute value). The intervertebral rotation difference in the axial plane was larger near the apical region (T8-T9), from 2.1° ± 2.7 to -14° ± 6.9, and smaller near the junctional region (T12-L1), from -2.6° ± 2.9 to -1.1° ± 8.4.
Conclusion: This case series suggests that corrective posterior spinal surgery for AIS using ST2R can achieve both 3D correction of the spine and additional intervertebral axial rotation, with minimal deterioration during follow-up. Preoperative, postoperative, and follow-up evaluation can be accurately evaluated with EOS low-dose 3D imaging.

The objective of this study was to establish the efficacy and safety of porous bioactive titanium metal for use in a spinal fusion device, based on a prospective human clinical trial. A high-strength spinal interbody fusion device was manufactured from porous titanium metal. A bioactive surface was produced by simple chemical and thermal treatment. Five patients with unstable lumbar spine disease were treated surgically using this device in a clinical trial approved by our Ethics Review Committee and the University Hospital Medical Information Network. Clinical and radiological results were reported at the minimum followup period of 1 year. The optimal mechanical strength and interconnected structure of the porous titanium metal were adjusted for the device. The whole surface of porous titanium metal was treated uniformly and its bioactive ability was confirmed before clinical use. Successful bony union was achieved in all cases within 6 months without the need for autologous iliac crest bone grafting. Two specific findings including an anchoring effect and gap filling were evident radiologically. All clinical parameters improved significantly after the operation and no adverse effects were encountered during the follow-up period. Although a larger and longer-term follow-up clinical study is mandatory to reach any firm conclusions, the study results show that this porous bioactive titanium metal is promising material for a spinal fusion device.

The growth of pulsed electromagnetic field (PEMF) therapy and its progress over the years for use in post-operative bone growth has been revolutionary in its effect on bone tissue proliferation and vascular flow. However, further progress in PEMF therapy has been difficult due to lack of more evidence-based understanding of its mechanism of action. Our objective was to review the current understanding of bone growth physiology, the mechanism of PEMF therapy action along with its application in spinal surgery and associated outcomes. The authors of this review examined multiple controlled, comparative, and cohort studies to compare fusion rates of patients undergoing PEMF stimulation. Examining spinal fusion rates, a rounded comparison of post-fusion outcomes with and without bone stimulator was performed. Results showed that postoperative spinal surgery PEMF stimulation had higher rates of fusion than control groups. Though PEMF therapy was proven more effective, multiple factors contributed to difficulty in patient compliance for use. Extended timeframe of treatment and cost of treatment were the main obstacles to full compliance. This review showed that PEMF therapy presented an increased rate of recovery in patients, supporting the use of these devices as an effective post-surgical aid. Given the recent advances in the development of PEMF devices, affordability and access will be much easier suited to the patient population, allowing for more readily available treatment options.

The growth of pulsed electromagnetic field (PEMF) therapy and its progress over the years for use in post-operative bone growth has been revolutionary in its effect on bone tissue proliferation and vascular flow. However, further progress in PEMF therapy has been difficult due to lack of more evidence-based understanding of its mechanism of action. Our objective was to review the current understanding of bone growth physiology, the mechanism of PEMF therapy action along with its application in spinal surgery and associated outcomes. The authors of this review examined multiple controlled, comparative, and cohort studies to compare fusion rates of patients undergoing PEMF stimulation. Examining spinal fusion rates, a rounded comparison of post-fusion outcomes with and without bone stimulator was performed. Results showed that postoperative spinal surgery PEMF stimulation had higher rates of fusion than control groups. Though PEMF therapy was proven more effective, multiple factors contributed to difficulty in patient compliance for use. Extended timeframe of treatment and cost of treatment were the main obstacles to full compliance. This review showed that PEMF therapy presented an increased rate of recovery in patients, supporting the use of these devices as an effective post-surgical aid. Given the recent advances in the development of PEMF devices, affordability and access will be much easier suited to the patient population, allowing for more readily available treatment options.

Objective: Posterior cervical spine surgery is used to decompress and/or stabilize the spine for the treatment of various spinal diseases. The aim of this study was to evaluate the clinical characteristics, surgical indications, and complications of patients who underwent posterior cervical spine surgery at a tertiary center. Methods: This retrospective cohort/case series study included data from patients who underwent posterior cervical spine surgery at a tertiary hospital to treat different cervical diseases. Results: A total of 161 patients were included. One hundred six (65.8%) patients were men, and mean age was 45.1 years. Patients with neoplastic diseases had the lowest mean age, whereas those with traumatic and degenerative diseases had the highest (p<0.001). Thirty-six patients (22.3%) experienced at least one complication. Serious adverse effects were infrequent despite six deaths (3.7%), and among the non-serious complications, surgical site infection (6.2%) and the need for late reoperation (4.3%) were the most common. No specific patient characteristics were associated with complications; however, a trend toward complications in urgent procedures was noted (p=0.085). Conclusion: Posterior cervical spine surgery was more common in men, and patients with degenerative diseases had a higher
average age. There was no statistically significant association between complications and patient characteristics, with a trend toward more clinical complications during urgent procedures. Serious complications were infrequent in elective procedures; however, a small risk of death was noted, particularly in patients with trauma-related cervical spine injuries. Understanding the epidemiology and complications is fundamental for preoperative counseling and the prevention of complications.

Background In patients with cervical spondylotic myelopathy, ventral disease and loss of physiological cervical lordosis are indications for anterior approach. As bone graft and titanium cage present many drawbacks, expandable titanium cage has been recently introduced for this indication. The authors present the clinical and radiological outcomes in patients undergoing the placement of an expandable cage in the treatment of spondylotic myelopathy with straight or kyphotic cervical spine alignment. Methods This was a retrospective review of prospectively collected data. A total of 26 patients underwent cervical corpectomy and reconstruction using an expandable titanium cage and anterior plate between 2005 and 2008. Pain and functional disability were measured using VAS and mJOA preoperatively and at 3 months, 6 months, 1 year and 2 years. Kyphosis was measured using lateral radiographs at the same points of follow-up. Fusion was evaluated on flexion-extension radiographs at 2 years. Results The mean VAS improved from 4.2 to 1.7 and the mean mJOA increased from 12.85 to 16.04 at 2 years postoperatively (p \ 0.05). The mean kyphosis angle decreased from 17°to 2°at the last follow-up (p \ 0.05). The fusion rate was 100 % at 2 years. Three complications were reported including a transient dysphagia, an epidural hematoma and an early hardware migration. Expandable titanium cage is an effective device, which achieves good clinical and radiological outcomes at a minimum 2-year follow-up.

Study Design: Pilot, single-center, single-blinded, parallel-group, randomized clinical study. Objective: The aim of this study was to pilot a randomized clinical study to evaluate whether instrumented anterior lumbar interbody fusion (ALIF) with a new nanocrystalline hydroxyapatite embedded in a silica gel matrix (NH-SiO2) leads to superior radiologic and clinical outcomes at 12-month follow-up compared with instrumented ALIF with homologous bone. Summary of Background Data: ALIF completed with interbody cages is an established technique for performing arthrodesis of the lumbar spine. There is ongoing discussion about which cage-filling material is most appropriate. This is the first study to assess the efficacy of NH-SiO2 in ALIF surgery. Materials and Methods: This randomized, clinical, pilot trial included 2 groups of 20 patients with monosegmental or multisegmental degenerative disease of the lumbar spine who were suitable to undergo monosegmental or bisegmental ALIF fusion at ...

Object. Pedicle screw fixation with transverse process fusion has gained widespread acceptance since its inception. Improved rates of arthrodesis have been demonstrated when this technique is used. The authors present one of the largest series of patients to undergo this procedure at a single center; one of the goals was to correlate construct length and spinal disease with rates of successful arthrodesis by conducting a prospective analysis of lumbar fusion in which pedicle screws were placed. Methods. During a 7-year period, the senior author performed pedicle screw fixation with posterolateral fusion in 457 patients; the mean follow-up period was 28.4 months. Indications for fusion included metastatic tumor, single-level degenerative disc disease (DDD), trauma, degenerative scoliosis, and translational vertebral instability. Successful fusion was based on the radiographic demonstration of a bilateral contiguous osseous bridge over the transverse processes and absence of movement ...

In this article the authors describe the management of Type II odontoid fractures with special attention to operative technique and avoidance of complication. Anterior odontoid screw fixation is a procedure the authors have performed over the last 8 years in cases with acute Type II and rostral Type III odontoid fractures. In cases of Chronic Type II odontoid fractures and in patients with transverse ligament disruption, the authors prefer to undertake posterior transarticular facet screw fixation supplemented by bone graft and interspinous C1–2 wiring. The technical aspects of these procedures are described with a focus on operative nuances. Selection criteria and techniques that the authors have refined over the years have helped them to optimize success rates and minimize complications.

The aim of this study was to determine whether obesity affects pain, surgical and functional outcomes following lumbar spinal fusion for low back pain (LBP). A systematic literature review and meta-analysis was made of those studies that compared the outcome of lumbar spinal fusion for LBP in obese and non-obese patients. A total of 17 studies were included in the meta-analysis. There was no difference in the pain and functional outcomes. Lumbar spinal fusion in the obese patient resulted in a statistically significantly greater intra-operative blood loss (weighted mean difference: 54.04 ml; 95% confidence interval (CI) 15.08 to 93.00; n = 112; p = 0.007) more complications (odds ratio: 1.91; 95% CI 1.68 to 2.18; n = 43858; p &lt; 0.001) and longer duration of surgery (25.75 mins; 95% CI 15.61 to 35.90; n = 258; p &lt; 0.001). Obese patients have greater intra-operative blood loss, more complications and longer duration of surgery but pain and functional outcome are similar to non-o...

Hydroxyapatite possesses desirable properties as a scaffold in tissue engineering: it is biocompatible at a site of implantation, and it is degradable to non-toxic products. Moreover, its porosity enables infiltration of cells, nutrients and waste products. The outcome of hydroxyapatite implantation highly depends on the extent of the host immune response. Authors emphasise major roles of the chemical, morphological and physical properties of the surface of biomaterial used. A number of techniques have been applied to transform the theoretical osteoconductive features of HAp into spinal fusion systems-from integration of HAp with autograft to synthetic intervertebral implants. The most popular uses of HAp in spine surgery include implants (ACDF), bone grafts in posterolateral lumbar fusion and transpedicular screws coating. In the past, autologous bone graft has been used as an intervertebral cage in ACDF. Due to the morbidity related to autograft harvesting from the iliac bone, a synthetic cage with osteoconductive material such as hydroxyapatite seems to be a good alternative. Regarding posterolateral lumbar fusion, it requires the graft to induce new bone growth and reinforce fusion between the vertebrae. Hydroxyapatite formulations have shown good results in that field. Moreover, the HAp coating has proven to be an efficient method of increasing screw fixation strength. It can decrease the risk of complications such as screw loosening after pedicle screw fixation in osteoporotic patients. The purpose of this literature review is to describe in vivo reaction to HAp implants and to summarise its current application in spine surgery.

Hydroxyapatite possesses desirable properties as a scaffold in tissue engineering: it is biocompatible at a site of implantation, and it is degradable to non-toxic products. Moreover, its porosity enables infiltration of cells, nutrients and waste products. The outcome of hydroxyapatite implantation highly depends on the extent of the host immune response. Authors emphasise major roles of the chemical, morphological and physical properties of the surface of biomaterial used. A number of techniques have been applied to transform the theoretical osteoconductive features of HAp into spinal fusion systems—from integration of HAp with autograft to synthetic intervertebral implants. The most popular uses of HAp in spine surgery include implants (ACDF), bone grafts in posterolateral lumbar fusion and transpedicular screws coating. In the past, autologous bone graft has been used as an intervertebral cage in ACDF. Due to the morbidity related to autograft harvesting from the iliac bone, a s...

Background: Ascorbic acid is involved in collagen biosynthesis and upregulates alkaline phosphatase, potentially alleviating cell senescence and stimulating mesenchymal stem cell proliferation and differentiation into osteoblasts. We hypothesized locally delivered ascorbic acid and b-glycerophosphate act as a bone graft extender to increase the volume of new bone formed in a murine model of posterior lumbar fusion. Methods: Collagen sponges were used as delivery vehicles. Sponges were prepared with primary media alone or with the addition of ascorbic acid and b-glycerophosphate. Fresh morselized bone graft from 12 donor mice was used. Twenty-four healthy male C57BL/6 mice underwent an uninstrumented posterior L3-L5 lumbar fusion. One control group received morselized bone only. A second ''sponge control'' group received morselized bone with the control collagen sponge. The third group received morselized bone and a collagen sponge with ascorbic acid and bglycerophosphate. Three months postoperatively, the lumbar spine underwent high-resolution micro-computed tomography for analysis of bone formation, density, and bridging fusion. Results: Animals receiving ascorbic acid and b-glycerophosphate had a statistically significant increase in corrected bone volume compared with control and sponge groups, with a 56.3% and 25.4% increase, respectively. Mineralized bone fraction was statistically significantly decreased for animals in the ascorbic acid group compared with control and sponge groups. There was no significant difference in fusion rate between test groups. Conclusions: Locally delivered ascorbic acid and b-glycerophosphate in a murine model of posterior spinal fusion yielded statistically significant increases in new bone formation in the lumbar spine but statistically significant decreases in mineralized bone fraction. Differences in fusion rate were not statistically significant. Clinical Relevance: This study provides early data suggesting that delivery of ascorbic acid to a spinal fusion site may be beneficial but does not yet establish an indication for clinical use. Further studies are needed to determine optimal dose and delivery of ascorbic acid.

Study Design. Systematic review. Objective. To review the published literature on the use of pedicle screws in pediatric spinal deformity to quantify the risks and complications associated with pedicle screw instrumentation, particularly in the thoracic spine. Summary of Background Data. The use of pedicle screws in adolescent scoliosis surgery is common. Although many reports have been published regarding the use of pedicle screws in pediatric patients, there has been no systematic review on the risks of complications. Methods. PubMed, Ovid Medline, and Cochrane databases were searched for studies reporting the use of thoracic pedicle screws in pediatric deformity. We excluded articles dealing with neuromuscular scoliosis or bone dysplasia to focus mostly on adolescent thoracic idiopathic scoliosis and the likes. We then searched for cases reports dealing with thoracic pedicle screws complications. Results. This systematic review retrieved 21 studies with a total of 4570 pedicle screws in 1666 patients. The mean age of the patients was 17.6 years; 812 patients were women and 252 were men, and 5 studies did not identify sex. Overall, 518 (4.2%) screws were reported as malpositioned. However, in studies in which postoperative computed tomography scans were done systematically, the rate of screw malpositioning was as high as 15.7%. The reported percentage of patients with screw malpositioned is around 11%. Eleven patients underwent revision surgery for instrumentation malposition. Other complications reported include loss of curve correction, intraoperative pedicle fracture or loosening, dural laceration, deep infection, pseudarthrosis, and transient neurologic injury. There were no major vascular complications reported in these 21 studies. We could identify 9 case report articles dealing with complications of pedicle screws. Such complications were mostly either vascular (10 cases) or neurologic (4 cases), without any irreversible complications. Conclusion. Malposition is the most commonly reported complication of thoracic pedicle screw placement, at a rate of 15.7% per screw inserted with postoperative computed tomography scans. The use of pedicle screws in the thoracic spine for the treatment of pediatric deformity has been reported to be safe despite the high rate of patients with malpositioned screws (11%). Major compli-cations, such as neurologic or vascular injury, were almost never reported in this literature review of case series. Cases reports on the other hand have started to identify such complications.

Study Design. The Morbidity and Mortality database of the Scoliosis Research Society (SRS) was queried as to the incidence and type of complications as reported by its members for the treatment of adolescent idiopathic scoliosis (AIS) with spinal fusion and instrumentation procedures regarding surgical approach (anterior, posterior, or combined anterior-posterior) during a recent 3-year period. Objective. To evaluate the incidence of surgeon-reported complications in a large series of spinal fusions with instrumentation for a single spinal deformity diagnosis and age group regarding surgical approach. Summary of Background Data. The SRS has been collecting morbidity and mortality data from its members since its formation in 1965 with the intent of using these data to assess the complications and adverse outcomes (death and/or spinal cord injury) of surgical treatment for spinal deformity. Surgical approaches to the management of treatment of AIS have a measurable impact on efficacy of correction, levels fused, and operative morbidity. However, there is a lack of consensus on the choice of surgical approach for the treatment of spinal deformity. Methods. Of the 58,197 surgical cases submitted by members of the SRS in the years 2001, 2002, and 2003, 10.9% were identified as having had anterior, posterior, or combined spinal fusion with instrumentation for the diagnosis of AIS, and comprised the study cohort. All reported complications were tabulated and totaled for each of the 3 types of procedures, and statistical analysis was conducted. Results. Complications were reported in 5.7% of the 6334 patients in this series. Of the 1164 patients who underwent anterior fusion and instrumentation, 5.2% had complications, of the 4369 who underwent posterior in-

Fifteen skeletally immature patients with double major adolescent idiopathic scoliosis with large lumbar curves and notable L4 and L5 coronal plane obliquity were retrospectively studied. Seven patients who underwent anterior release and fusion of the lumbar curve with segmental anterior instrumentation and subsequent posterior instrumentation ending at L3 were compared with eight patients treated with anterior release and fusion without anterior instrumentation followed by posterior instrumentation to L3 or L4. At 4.5 years follow-up (range 2.5-7 years), curve correction, coronal balance and fusion rate were not statistically different between the two groups; however, the group with anterior instrumentation had improved coronal plane, near normalangulation in the distal unfused segment compared with the group without anterior instrumentation. In cases involving severe lumbar curva-tures in the context of double major scoliosis, when as a first stage anterior release is chosen, the addition of instrumentation appears to restore normal coronal alignment of the distal unfused lumbar segment, and may in certain cases save a level compared with traditional fusions to L4.

Spinal cord stimulators (SCS) are a well-recognised treatment modality in the management of a number of chronic neuropathic pain conditions, particularly failed back syndrome and radiculopathies. The implantable pulse generator (IPG) component of the SCS is designed and operates in a similar fashion to that of a cardiac pacemaker. The IPG consists of an electrical generator, lithium battery, transmitter/receiver and a minicomputer. When stimulated, it generates pulsed electrical signals which stimulate the dorsal columns of the spinal cord, thus alleviating pain. Analogous to a cardiac pacemaker, it can be potentially damaged by ionising radiation from a linear accelerator, in patients undergoing radiotherapy. Herein we report our clinical management of the first reported case of a patient requiring adjuvant breast radiotherapy who had a SCS in situ. We also provide useful practical recommendations on the management of this scenario within a radiation oncology department.

It is not always easy to predict the degree of symptomatic improvement to be expected in a patient undergoing surgery for cervical disc herniation and radiculopathy. Here we investigate whether preoperative electromyography (EMG) can help select those most likely to benefit from intervention. We prospectively evaluated 20 patients whose required operative level was unclear after clinical examination and MRI scan alone. The surgical procedures was anterior cervical interbody fusion with the AcroMed Ò carbon fibre cage. Clinical assessment employed using validated scoring systems (Prolo functional and economic scoring system). Patients underwent MRI preoperatively, and were assessed pre and postoperatively with neurophysiological studies (NPS) including nerve conduction studies and concentric needle EMG. Patients with preoperative evidence of cervical nerve root involvement on EMG (group A, n = 8) had better outcome (P = 0.001) following discectomy and anterior fusion than patients who had no evidence of nerve root damage on EMG (group B, n = 12). Prolo mean score ± SEM for group A was 7.375 ± 0.3750 and for group B was 5.583 ± 0.2876. Thus, NPS are a valuable tool in selecting patients in this subgroup for cervical surgery.

Venous air embolism (VAE) is a known neurosurgical complication classically and most frequently occurring in patients undergoing posterior cranial fossa or cervical spine surgery in a sitting or semi-sitting position. The authors present a case of VAE that occurred during posterior cervical spine surgery in a patient in the prone position, a rare intraoperative complication. The patient was a 65-year-old man who was undergoing a C1-2 fusion for a nonunion of a Type II dens fracture and developed a VAE. While VAE in the prone position is uncommon, it is a neurosurgical complication that may have significant clinical implications both intraoperatively and postoperatively. The aim of this review is 2-fold: 1) to improve the general knowledge of this complication among surgeons and anesthesiologists who may not otherwise suspect air embolism in patients positioned prone for posterior cervical spine operations, and 2) to formulate preventive measures as well as a plan for prompt diagnosi...

Previous studies have confirmed the benefits and limitations of the presacral retroperitoneal approach for L5-S1 interbody fusion. The purpose of this study was to determine the safety and effectiveness of the minimally invasive axial lumbar interbody approach (AxiaLIF) for L4-S1 fusion. Methods: In this retrospective series, 52 patients from four clinical sites underwent L4-S1 interbody fusion with the AxiaLIF two-level system with minimum 2-year clinical and radiographic follow-up (range: 24-51 months). Outcomes included back pain severity (on a 10-point scale), the Oswestry Disability Index (ODI), and Odom's criteria. Flexion and extension radiographs, as well as computed tomography scans, were evaluated to determine fusion status. Longitudinal outcomes were assessed with repeated measures analysis of variance. Results: Mean subject age was 52 ± 11 years and the male:female ratio was 1:1. Patients sustained no intraoperative bowel or vascular injury, deep infection, or neurologic complication. Median procedural blood loss was 220 cc and median length of hospital stay was 3 days. At 2-year follow-up, mean back pain had improved 56%, from 7.7 ± 1.6 at baseline to 3.4 ± 2.7 (P , 0.001). Back pain clinical success (ie, $30% improvement from baseline) was achieved in 39 (75%) patients at 2 years. Mean ODI scores improved 42%, from 60% ± 16% at baseline to 35% ± 27% at 2 years (P , 0.001). ODI clinical success (ie, $30% improvement from baseline) was achieved in 26 (50%) patients. At final follow-up, 45 (87%) patients were rated as good or excellent, five as fair, and two as poor by Odom's criteria. Interbody fusion observed on imaging was achieved in 97 (93%) of 104 treated interspaces. During follow-up, five patients underwent reoperation on the lumbar spine, including facet screw removal (two), laminectomy (two), and transforaminal lumbar interbody fusion (one). The AxiaLIF two-level device is a safe, effective treatment adjunct for patients with L4-S1 disc pathology resistant to conservative treatments.

A truss structure was recently introduced as an interbody fusion cage. As a truss system, some of the connected elements may be in a state of compression and others in tension. This study aimed to quantify both the mean and variance of strut strains in such an implant when loaded in a simulated fusion condition with vertebral body or contoured plastic loading platens ex vivo. Cages were each instrumented with 78 fiducial spheres, loaded between platens (vertebral body or contoured plastic), imaged using high resolution micro-CT, and analyzed for deformation and strain of each of the 221 struts. With repeated loading of a cage by vertebral platens, the distribution (variance, indicated by SD) of strut strains widened from 50 N control (4 ± 114 με, mean ± SD) to 1000 N (-23 ± 273 με) and 2000 N (-48 ± 414 με), and between 1000 N and 2000 N. With similar loading of multiple cages, the strain distribution at 2000 N (23 ± 389 με) increased from 50 N control. With repeated loading by contoured plastic platens, induced strains at 2000 N had a distribution similar to that induced by vertebral platens (84 ± 426 με). In all studies, cages exhibited increases in strut strain amplitude when loaded from 50 N to 1000 N or 2000 N. Correspondingly, at 2000 N, 59-64% of struts exhibited strain amplitudes consistent with mechanobiologically-regulated bone homeostasis. At 2000 N, vertically-oriented struts exhibited deformation of -2.87 ± 2.04 μm and strain of -199 ± 133 με, indicating overall cage compression. Thus, using an ex vivo 3-D experimental biomechanical analysis method, a truss implant can have

To raise the awareness of the appropriate management of unusual clinical presentation of cervical disc herniation. mAterIAl and methOds: Seven patients with Brown-Sequard syndrome due to cervical disc herniation presented with Brown-Sequard syndrome had been treated surgically as one of them treated with anterior cervical discectomy and three patients treated by anterior cervical discectomy and fusion while three of them have been treated by posterior laminectomy. results: Patients were 7 three of them were female and four were males and the mean age of our patients is 45.28±16.49 years ranged between 32 and 72 years. History of spinodegenerative disease in the form of chronic neck pain with or without brachialgia was found in 6/7 patients (85.7%) while history of trauma was found in 5/7 patients (71.4%). Most common affected level is C5-C6 disc Outcome after surgical treatment revealed complete recovery in 4/7 patients (57.1%) while incomplete recovery in 2 patients (28.6%) and no improvement in one patient (14.3%). COnClusIOn: Brown-Sequard syndrome is a rare presentation of cervical disc herniation but accurate diagnosis, and early anterior spinal cord decompression lead to complete recovery of these cases.

Elderly patients with chronic nonresolving symptoms due to degenerative spine pathologies are prone to have poor surgical outcomes and hardware-related complications, especially following multilevel instrumented lumbar fusion surgeries. With intention of analyzing if teriparatide can be an effective adjunct therapy to surgical management, radiological outcomes are studied. Sixty-two elderly patients were divided into 2 similar groups. Group 1 (n = 30; mean age = 69.83 years; fusion levels = 137; screws = 269) had taken teriparatide (20 mcg SC injection, once daily) for a duration of 7.4 ± 2.4 months following surgery and Group 2 (n = 32; mean age = 70.38 years; fusion levels = 144; screws = 283) did not take teriparatide. Radiological evaluation was done to determine the state of postero lateral fusion mass and to investigate the incidence of pedicle screw loosening at 1-year follow-up. Unilateral or bilateral bridging bone formation across the transverse process of adjacent vertebr...

Percutaneous pedicle screw instrumentation is a minimally invasive surgical technique; however, the effects of using percutaneous pedicle screw fixation in treating patients with spinal infections have not yet been well demonstrated. The aim of this study, therefore, was to determine whether percutaneous posterior pedicle screw instrumentation is superior to the traditional open approach in treating pyogenic spondylodiscitis. We retrospectively reviewed data for 45 patients treated for pyogenic spondylodiscitis with anterior debridement and interbody fusion followed by a second-stage procedure involving either traditional open posterior pedicle screw fixation or percutaneous posterior pedicle screw fixation. Twenty patients underwent percutaneous fixation and 25 patients underwent open fixation. Demographic, operative, and perioperative data were collected and analyzed. The average operative time for the percutaneous procedure was 102.5 minutes, while the average time for the open p...

While anterior-approach lumbar disc replacement devices are thought to retain close to "normal" range-of-motion (ROM), they are also inherently unstable due to resection of the anterior longitudinal ligament and annulus. This instability/laxity is manifested as increased neutral zone motion. The XL-TDR device (Nuvasive, Inc., San Diego, CA) is implanted through a lateral approach that preserves the anterior ligamentous and annular structures. This potentially makes the XL-TDR device significantly more stable than those delivered anteriorly. This study investigates the kinematics of XL-TDR in a cadaveric model, and also investigates the contribution of the anterior ligament/annulus to stability. Methods: Six fresh-frozen cadaveric specimens (L2-S1) were subjected to non-destructive multidirectional testing using the hybrid protocol described by Panjabi, where the total L2-S1 intact ROM at ±8 N•m is applied to the reconstructed conditions. Motion segment kinematics were obtained using an optoelectronic system. Test conditions were: (1) intact spine, (2) XL-TDR at L4-5, and (3) XL-TDR at L4-5 with anterior annulus/ligament resected. Total ROM (ROM = NZ + EZ; NZ = neutral zone, EZ = elastic zone) and NZ were calculated for each condition in each loading direction (flexion-extension total, flexion alone, extension alone, lateral bending and axial rotation). Results: Insertion of the XL-TDR device led to decreased ROM with respect to intact in all directions. This achieved statistical significance for flexion-extension, extension, and axial rotation (p < 0.006). NZ in all directions was not statistically different from intact (p < 0.05; Figure ), although there was a trend towards decreased NZ in flexion (p = 0.078). Removing the anterior ligament/annulus increased ROM significantly with respect to the XL-TDR condition in all directions (p < 0.003). NZ also increased, with the most significant changes in extension, lateral bending and axial rotation (p < 0.002).

Choosing the appropriate graft material to participate in the healing process in posterolateral spinal fusion continues to be a challenge. Combining synthetic graft materials with bone marrow aspirate (BMA) and autograft is a reasonable treatment option for surgeons to potentially reduce or replace the need for autograft. FormaGraft, a bone graft material comprising 12% bovine-derived collagen and 88% ceramic in the form of hydroxyapatite (HAp) and beta tricalcium phosphate (b-TCP) was evaluated in three possible treatment modalities for posterior spinal fusion in a standard rabbit model. These three treatment groups were FormaGraft alone, FormaGraft soaked in autogenous BMA, and FormaGraft with BMA and iliac crest autograft. No statistically demonstrable benefits or adverse effects of the addition of BMA were found in the current study based on macroscopic, radiology or mechanical data. This may reflect, in part, the good to excellent results of the collagen HA/TCP composite material alone in a well healing bony bed. Histology did, however, reveal a benefit with the use of BMA. Combining FormaGraft with autograft and BMA achieved results equivalent to autograft alone. The mineral and organic nature of the material provided a material that facilitated fusion between the transverse processes in a standard preclinical posterolateral fusion model.

Introduction: Forestier's disease, also known as diffuse idiopathic skeletal hyperostosis, is a systemic, non-inflammatory disease of unknown etiology, common in men over 50 years of age and consisting of calcification and ossification of peripheral ligaments and enthesis, with great selectivity for the anterior portion of the spine.
Clinical Case: A 56-year-old male patient with a history of hypertension and type 2 diabetes mellitus, with a seven-year history of progressive dysphagia and rigidity in neck movements. Radiographic, tomographic and magnetic resonance imaging studies showed multisegmented hyperostosis of the anterior longitudinal ligament from C2 to T3, with prominent osteophytes that contact the prevertebral soft tissues, in addition to confirmation of mechanical dysphagia by esophagogram with barium contrast.
Conclusion: Surgical treatment of Forestier's disease has been shown to be highly effective in cases with severe symptoms, such as dysphagia. When conservative treatment fails, the resection of symptomatic anterior osteophytes emerges as a safe and promising procedure for long-term relief.

The use of spinal implants for spine fusion has been steadily increasing to avoid the risks of complications and donor site morbidity involved when using autologous bone. A variety of fusion cages are clinically available, with different shapes and chemical compositions. However, detailed information about their surface properties and the effects of such properties on osteogenesis is lacking in the literature. Here we evaluate the role of surface properties for spinal implant applications, covering some of the key biological processes that occur around an implant and focusing on the role of surface properties, specifically surface structure, on osseointegration, drawing examples from other implantology fields when required. Our findings revealed that surface properties such as micro-roughness and nanostructures can directly affect early cell behavior and long-term osseointegration. Micro-roughness has been well established in the literature to have a beneficial effect on osseointegration of implants. In the case of the role of nanostructures, the number of reports is increasing and most studies reveal a positive effect from the nanostructures alone and a synergistic effect when combined with micro-rough surfaces. Still, long-term clinical results are necessary to establish the full implications of surface nanomodifications.

A estenose de canal vertebral é uma doença degenerativa da coluna vertebral estreitamente relacionada ao envelhecimento humano, pois tem como causa a doença degenerativa dos discos intervertebrais e artrose das facetas articulares posteriores da coluna vertebral, com conseqüente estreitamento do canal vertebral. Com o aumento da longevidade da população, é esperada também maior freqüência de pacientes com doenças degenerativas da coluna vertebral, necessitando uma abordagem clínica adequada. Dessa forma apresentamos um artigo abordando aspectos clínicos, diagnósticos e tratamentos da estenose do canal vertebral.

Microlumbar discectomy is one of the debatable topics of spine surgery. The most important question is “Can we decrease the unsatisfactory results with microsurgery?” If we lock at the literature, we can see the successful results with microsurgery. There is no doubt microsurgery helps some parameters such as short operation time, minimal tissue damage, short hospital stay and in many cases short rehabilitation duration before the job (1). But in some literature findings in overall results there are no big differences between the discectomy with microsurgery and microdiscectomy (2). The important question is which factors effect on the unsuccessful results? Are these patient’s history, neurological examination and MRI evaluation? When the patient tells his/her history, two points is remarkable. The first point is the previous low back pain before the extremity pain. The patient gives at least two, three or more sudden low back pain attacks or complains constant back pain in daily li...

to some limitations in the long term. The biomechanics of the spine are also changing, because it creates non-physiological conditions by blocking movement (16). The idea of fusion in spinal surgery was raised for the first time at the beginning of the last century. When looking at the literature, it has been shown that the importance of spinal fusion was not exactly known before this period, and surgeons were content with fixation. Thereafter, the first fixation in the thoracolumbar spine by using wire was performed by Hadra █ INTRODUCTION T oday, posterior spinal stabilization and fusion interventions occupy an important place in neurosurgical practice. Spinal fusion and instrumentation are often applied to provide stability for an unstable spine, to avoid injury in the neurological structure, to reduce incorrect alignment and deformities, to increase the probability of fusion, and to reduce pain in the long term (8). Although this procedure has a very high success rate, the mechanism of the procedure can lead AIm: Many studies are available in the literature on posterior spinal instrumentation, though the use of a rod and a plate is still controversial in the literature. In this study, a finite element analysis of the strength and superiority of modular rigid plate and rod systems, which are used in the lower lumbar region, in comparison with each other was used. mATERIAl and mEThODS: A Ti6Al4V (Grade 5) titanium biocompatible alloy anterior plate was used for the lumbar spine fixation device, and a finite element analysis was conducted on the human lumbar spine model. In this study, an intact spine, a rigid system fixed with a rod, and modular plate systems were evaluated at flexion, extension, lateral bending, and axial rotation. They did not show statistically significant superiority over one another in terms of limitations in movement during the range of motion exercises and rigidity. The posterior rigid stabilization system and novel stabilization system do not have a significant superiority over one another. Equivalent results in the limitation of movement and rigidity allow for the use of these systems for short-segment posterior spinal instrumentation with the same indications.