Spinal fusion is a well-established procedure in the treatment of degenerative spinal diseases. Previous research shows that the use of this operative treatment has been growing in recent decades in ...industrialized countries and has become one of the most cost-intensive surgical procedures. It seems that in some countries such as Germany-with its large, industrialized, European population-this increase is mainly driven by demographic changes with low fertility rates, increasing life expectancy, and an aging population. Based on current projections, however, Germany faces a population trend that many other countries are likely to follow within a few decades. An increasingly shrinking and aging working population may eventually put the healthcare system under enormous pressure, with greater demands for spinal fusions and associated higher costs. Thus, we aimed to provide reliable projections regarding the future demand for posterior spinal fusion procedures including age- and gender-related trends up to 2060, which will be necessary for future resource planning and possible improvements in actual treatment strategies.
(1) How is the use of posterior spinal fusions in Germany expected to change from 2019 through 2060, if currents trends continue? (2) How is the use of posterior spinal fusions in Germany expected to change depending on patients' age and gender during this time period?
Comprehensive nationwide data provided by the Federal Statistical Office, the official institution for documenting all data on operations and procedures performed in Germany, were used to quantify posterior spinal fusion rates as a function of calendar year, age, and gender. Because there is a lack of evidence regarding future trends in the use of posterior spinal fusions, an autoregressive integrated moving average model on historical procedure rates from 2005 to 2019 in relation to official population projections from 2020 to 2060 was chosen to forecast future absolute numbers and incidence rates of this procedure in Germany. Long-term forecasting is more prone to unexpected disruptions than forecasting over short-term periods; however, longer spans facilitate estimates of how trends may challenge future healthcare systems if those trends continue, and thus are useful for research and planning.
The incidence rate of posterior spinal fusion was projected to increase by approximately 83% (95% CI 28% to 139%) to 102% per 100,000 inhabitants (95% CI 71% to 133%) in 2060, with a 1.3-fold higher rate of women undergoing surgery in terms of absolute numbers. The highest increase identified by the model occurred in patients 75 years and older with 38,974 (95% CI 27,294 to 50,653) posterior spinal fusions in 2060, compared with 14,657 in 2019. This trend applied for both women and men, with a 246% (95% CI 138% to 355%) increase in the total number of posterior spinal fusions for women 75 years and older and a 296% (95% CI 222% to 370%) increase for men 75 years and older. At the same time, posterior spinal fusions in all age groups younger than 55 years were projected to follow a constant or even negative trend up to 2060.
Our findings suggest that increasing use of posterior spinal fusion, particularly in patients 75 years and older, will challenge healthcare systems worldwide if current trends persist. This study may serve as a model for many other industrialized countries facing similar demographic and procedure-specific developments in the future. This emphasizes the need to focus on frailty research as well as appropriate financial and human resource management. Effective perioperative medical management, multidisciplinary treatment, and interinstitutional protocols are warranted, especially in older patients as we attempt to manage these trends in the future.
Level III, economic and decision analysis.
Vertebral body replacement is a common surgical procedure for treatment of disorders associated with spinal instability. Therefore, pedicle screws are usually inserted in adjacent vertebrae for ...stabilization of the posterior column, however, there is lack of evidence whether implantation of index-level pedicle screws is beneficial or not. This biomechanical study aims to investigate the effect of pedicle screw instrumentation on axial stability following vertebral body replacement.
Unstable fracture at L3 level was simulated in lumbar spines from six human cadaveric specimens. Then instrumentation was performed one level above / one level below index level in three specimens and further, three specimens were instrumented at index-level (L3) additionaly. Then we used a testing protocol for biomechanical evaluation of axial loading on human cadaveric lumbar spines until cage subsidence occurred.
Our results show that index-level instrumented spines endured significantly higher load until cage subsidence occurred compared to non-index-level instrumented specimens (p = 0.05).
Our results demonstrate pedicle screw instrumentation at index-level vertebra should be considered when possbile as it may have a protective effect against cage subsidence in patients undergoing vertebral body replacement surgery.
•Biomechanical testing of axial loading after vertebral body replacement.•Index-level instrumented spines endured significantly higher load than without.•Index-level pedicle screw instrumentation significantly increases axial loading capability.
Dural tears (DTs) are a frequent complication after lumbar spine surgery. We sought to determine the incidence of DTs and the related impact on health care expenditures after lumbar discectomies.
In ...this retrospective cohort study, all patients with first-time single-level lumbar discectomies at our institution who underwent minimally invasive surgery from 2015 to 2019 were reviewed. Age, sex, weight, height, body mass index, costs, revenues, length of stay, American Society of Anesthesiologists score, Charlson Comorbidity Index, and operative time (OT) were assessed. Exclusion criteria were age <18 years, previous spine surgery, multiple or traumatic disc herniations, and malignant and infectious diseases.
The follow-up time was at least 12 months postoperatively. Of 358 patients identified with lumbar discectomies, 230 met the inclusion criteria. Incidence of DTs was 3.5%. Mean costs (P < 0.001), economic loss (P < 0.01), and OT (P < 0.0001) were found to be significantly higher in the DT group compared with the control group of patients without a DT. The revenues were not statistically different between the 2 groups (P > 0.05). Further analysis of the control group by profit and loss revealed significantly higher body mass index (P < 0.05), length of stay (P < 0.0001), and OT (P < 0.0001) in the loss group.
DTs represent a significant socioeconomic burden in lumbar spine surgery and cause severe secondary complications. The impact of DTs on health care expenses is primarily based on significantly higher OT and a higher mean length of stay.
Pedicle screw instrumentation has become “state of the art” in surgical treatment of many spinal disorders. Loosening of pedicle screws due to poor bone mineral density is a frequent complication in ...osteoporotic patients. As prevalence of osteoporosis and spinal disorders are increasing with an aging demographic, optimizing the biomechanical properties of pedicle screw constructions and therefore outcome after spinal surgery in osteoporotic patients is a key factor in future surgical therapy. Therefore, this biomechanical study investigated the stability of polymethylmethacrylate (PMMA)‐augmented pedicle screw‐rod constructions under a deviating distribution of PMMA applied to the instrumentation in osteoporotic human cadaveric vertebrae. We showed that PMMA‐augmented pedicle screw‐rod constructions tend to be more stable than those with non‐augmented pedicle screws. Further, there appears to be a larger risk of screw loosening in unilateral augmented pedicle screws than in non‐augmented, therefore a highly asymmetrically distributed PMMA should be avoided.
Purpose
To outline clinical effectiveness of continuous epidural analgesia (CEA) in patients with failed back surgery syndrome (FBSS) or lumbar spinal stenosis (LSS) depending on severity of spinal ...degeneration.
Methods
In this retrospective cohort study, all patients with FBSS or LSS who underwent CEA within an inpatient rehabilitation program were evaluated. The pain reduction was measured by VAS on an hourly basis. Substantial pain reduction was defined as a minimal clinically important difference (MCID) > 50%. Severity of spinal degeneration, side effects and patient-specific characteristics were documented.
Result
We included a total of 148 patients with 105 patients suffering from FBSS and 48 with LSS. The average pain reduction was − 37.6 ± 19.2 in FBSS and − 38.1 ± 17.8 in LSS group (
p
< .001 and
p
< .001, respectively). In the FBSS group, sensory deficits (
p
= .047) and numbness (
p
= .002), and in the LSS group, a severe disability measured by ODI (38.2 ± 15.4 vs. 57.3 ± 11.3,
p
< .001) significantly contributed to a worse outcome. The severity of the spinal degeneration and psychological disorders did not affect the pain reduction in terms of MCID.
Conclusions
This study provides new evidence about CEA in the treatment of FBSS and LSS. CEA provides a significant pain reduction even under intensified physiotherapeutic exercising in patients with severe spinal degeneration and a broad variety of secondary diagnoses. Neurologic deficits in case of FBSS and severe disability in case of LSS may be risk factors for less favorable outcome.
Purpose
The purpose of this study was to outline the feasibility of continuous epidural analgesia in the treatment of failed back surgery syndrome (FBSS) or spinal stenosis.
Methods
We queried our ...prospective collected institutional database to include all consecutive patients, who underwent continuous epidural analgesia with accompanying intensive physiotherapeutic exercise within a timeframe of 4 years. Patients suffered from FBSS or spinal stenosis; protocolled continuous epidural analgesia was planned for 4 days within the framework of an inpatient multimodal pain therapy concept. The instillation technique of the epidural catheter, the capability to attend in accompanying physiotherapy, and the peri-interventional complications were evaluated.
Results
153 patients with an average age of 57.4 years (± 11.9) were enrolled in this study. 105 patients suffered from FBSS and 48 patients had spinal stenosis. Overall, 148 patients (96.7%) reported the pain reduction and were able to perform daily intensified physiotherapeutic exercise. There were no serious adverse events, neither infection nor bleeding, no cardiopulmonary complication or permanent neurological deficits. The most common side effect was neurological impairment, such as numbness, dysesthesia, or weakness of the lower limbs with complete regression after flow rate adjustment. Patients with FBSS were more likely to develop dysesthesia (
p
= 0.007).
Conclusions
Continuous epidural analgesia is feasible in patients with FBSS or spinal stenosis. This treatment enables extensive physiotherapeutic treatment even in patients with severe pain conditions and can be considered as an alternative to epidural injections. An increased complication rate in comparison to short-term perioperative or perinatal application was not observed.
The 16 kDa heat shock protein (HSP) is an immuno-dominant antigen, used in diagnosis of infectious Mycobacterium tuberculosis (M.tb.) causing tuberculosis (TB). Its use in serum-based diagnostics is ...limited, but for the direct identification of M.tb. bacteria in sputum or cultures it may represent a useful tool. Recently, a broad set of twelve 16 kDa specific heavy chain llama antibodies (VHH) has been isolated, and their utility for diagnostic applications was explored.
To identify the epitopes recognized by the nine (randomly selected from a set of twelve 16 kDa specific VHH antibodies) distinct VHH antibodies, 14 overlapping linear epitopes (each 20 amino acid long) were characterized using direct and sandwich ELISA techniques. Seven out of 14 epitopes were recognized by 8 out of 9 VHH antibodies. The two highest affinity binders B-F10 and A-23 were found to bind distinct epitopes. Sandwich ELISA and SPR experiments showed that only B-F10 was suitable as secondary antibody with both B-F10 and A-23 as anchoring antibodies. To explain this behavior, the epitopes were matched to the putative 3D structure model. Electrospray ionization time-of-flight mass spectrometry and size exclusion chromatography were used to determine the higher order conformation. A homodimer model best explained the differential immunological reactivity of A-23 and B-F10 against heat-treated M.tb. lysates.
The concentrations of secreted antigens of M.tb. in sputum are too low for immunological detection and existing kits are only used for identifying M.tb. in cultures. Here we describe how specific combinations of VHH domains could be used to detect the intracellular HSP antigen. Linked to methods of pre-concentrating M.tb. cells prior to lysis, HSP detection may enable the development of protein-based diagnostics of sputum samples and earlier diagnosis of diseases.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
ABSTRACT Background: Overview of the literature – Fractures of the C1 constitute 3%–13% of all cervical spine injuries in adults. Most isolated C1 fractures are stable and can be treated ...nonoperatively with external immobilization. Traditional surgical options for C1 fracture treatment are occiput-to-C2 fusion or C1 with lateral mass screws (LMSs). Purpose – The aim is to assess the management and perioperative complications of C1 fractures undergoing LMS fusion between fluoroscopy and computed tomography (CT)-guided navigation. Methods: This was a retrospective multicenter study of data from the DWG-Register of patients who underwent operative treatment for C1 traumatic fracture with LMSs from January 2017 to September 2022. Inclusion criteria – traumatic injury and age > 18 years old. Results: In total, 202 patients with traumatic C1 fracture requiring spinal surgery were identified in the registry; n = 175 (Group 1) were treated conventionally without CT-guided navigation and n = 27 were treated with CT-guided navigation (Group 2). C1-LMS was principally performed by spine surgeons n = 90 (53.4%) and n = 72 (18.5%) by neurosurgeons in both the groups. Intraoperative adverse events were as follows: dural tear in group 1 n = 0 and in group 2 n = 1, vascular injury, with one case in group 1 and no cases in group 2. General complications were: cardiovasculars in group 1 n = 6 (3.4%) and Group 2 n = 4 (14.8%) ( P = 0.03), pulmonary complications in group1 n = 2 (1.1%) and n = 9 in group 2 (33.3%) ( P < 0.001), stroke n = 1 (0.57%) in group1 and n = 4 in group 2 (14.8%) ( P < 0.001), gastrointestinal bleeding n = 1 (0.57%) in group1 and no cases in group 2, renal insufficiency n = 2 (1.1%) in group 1 and n = 3 (11.1%) in group 2 ( P = 0.01) .One death was recorded in group 2 (3.7%). Conclusion: This series of 404 screws placed in 202 patients over 5 years who underwent two types of C1 fracture fixation had a considerably lower incidence of screw malposition and vertebral artery injury than has previously been reported in the literature. C1 screws can be safely placed with a low risk of vertebral artery and neurologic injury with and without CT-guided navigation support.
Objective
To assess which radiological alignment parameters are associated with a satisfactory long‐term clinical outcome after performing lumbar spinal fusion for treating degenerative ...spondylolisthesis.
Methods
This single‐center prospective study assessed the relation between radiological alignment parameters measured on standing lateral lumbar spine radiographs and the patient‐reported outcome using four different questionnaires (COMI, EQ‐5D, ODI and VAS) as primary outcome measures (level of evidence: II). The following spinopelvic alignment parameters were used: gliding angle, sacral inclination, anterior displacement, sagittal rotation, lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence. Furthermore, the length of stay and perioperative complications were documented. Only cases from 2013 to 2015 of low‐grade degenerative lumbar spondylolisthesis (Meyerding grades I and II) were considered. The patients underwent open posterior lumbar fusion surgery by pedicle screw instrumentation and cage insertion. The operative technique was either a posterior lumbar interbody fusion (PLIF) or a transforaminal lumbar interbody fusion (TLIF) performed by three different senior orthopedic surgeons. Exclusion criteria were spine fractures, minimally invasive techniques, underlying malignant diseases or acute infections, previous or multisegmental spine surgery as well as preoperative neurologic impairment. Of 89 initially contacted patients, 17 patients were included for data analysis (11 males, six females).
Results
The data of 17 patients after mono‐ or bisegmental lumbar fusion surgery to treat low‐grade lumbar spondylolisthesis and with a follow‐up time of least 72 months were analyzed. The mean age was 66.7 ± 11.3 years. In terms of complications two dural tears and one intraoperative bleeding occurred. The average body mass index (BMI) was 27.6 ± 4.4 kg/m2 and the average inpatient length of stay was 12.9 ± 3.8 days (range: 8–21). The long‐term clinical outcome correlated significantly with the change of the pelvic tilt (rs = −0.515, P < 0.05) and the sagittal rotation (rs = −0.545, P < 0.05). The sacral slope was significantly associated with the sacral inclination (rs = 0.637, P < 0.01) and the pelvic incidence (rs = 0.500, P < 0.05). In addition, the pelvic incidence showed a significant correlation with the pelvic tilt (rs = 0.709, P < 0.01). The change of the different clinical scores over time also correlated significantly between the different questionnaires.
Conclusions
The surgical modification of the pelvic tilt and the sagittal rotation are the two radiological alignment parameters that can most accurately predict the long‐term clinical outcome after lumbar interbody fusion surgery.
Pre‐ and postoperative (PLIF L4/5) lateral standing radiographs of the lumbar spine are used to measure the pelvic tilt. The greater the difference of the pelvic tilt after fusion surgery compared to the preoperative value, the worse is the outcome after 6 years when quantified by the EQ‐5D questionnaire.
Departments of 2 Pediatrics, 3 Orthopedics, 4 Microbiology and Molecular Genetics, and 5 Biological Chemistry, 1 Center for the Study of Health Effects of Exercise in Children, 7 Department ...Physiology and Biophysics, 6 Institute for Genomics and Bioinformatics, College of Medicine, University of California, Irvine, California 92697
Submitted 25 March 2004
; accepted in final form 6 June 2004
Exercise leads to increases in circulating levels of peripheral blood mononuclear cells (PBMCs) and to a simultaneous, seemingly paradoxical increase in both pro- and anti-inflammatory mediators. Whether this is paralleled by changes in gene expression within the circulating population of PBMCs is not fully understood. Fifteen healthy men (1830 yr old) performed 30 min of constant work rate cycle ergometry ( 80% peak O 2 uptake). Blood samples were obtained preexercise (Pre), end-exercise (End-Ex), and 60 min into recovery (Recovery), and gene expression was measured using microarray analysis (Affymetrix GeneChips). Significant differential gene expression was defined with a posterior probability of differential expression of 0.99 and a Bayesian P value of 0.005. Significant changes were observed from Pre to End-Ex in 311 genes, from End-Ex to Recovery in 552 genes, and from Pre to Recovery in 293 genes. Pre to End-Ex upregulation of PBMC genes related to stress and inflammation e.g., heat shock protein 70 (3.70-fold) and dual-specificity phosphatase-1 (4.45-fold) was followed by a return of these genes to baseline by Recovery. The gene for interleukin-1 receptor antagonist (an anti-inflammatory mediator) increased between End-Ex and Recovery (1.52-fold). Chemokine genes associated with inflammatory diseases macrophage inflammatory protein-1 (1.84-fold) and -1 (2.88-fold), and regulation-on-activation, normal T cell expressed and secreted (1.34-fold) were upregulated but returned to baseline by Recovery. Exercise also upregulated growth and repair genes such as epiregulin (3.50-fold), platelet-derived growth factor (1.55-fold), and hypoxia-inducible factor-I (2.40-fold). A single bout of heavy exercise substantially alters PBMC gene expression characterized in many cases by a brisk activation and deactivation of genes associated with stress, inflammation, and tissue repair.
microarray; inflammation; growth; immunity
Address for reprint requests and other correspondence: D. M. Cooper, Center for the Study of Health Effects of Exercise in Children, Dept. of Pediatrics, Bldg. 25, 2nd Floor, 101 The City Dr., Orange, CA 92868 (E-mail: dcooper{at}uci.edu ).
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