Biomarkers are biological characteristics that can be used to indicate health or disease. This paper reviews studies on biomarkers of low back pain (LBP) in human subjects. LBP is the leading cause ...of disability, caused by various spine‐related disorders, including intervertebral disc degeneration, disc herniation, spinal stenosis, and facet arthritis. The focus of these studies is inflammatory mediators, because inflammation contributes to the pathogenesis of disc degeneration and associated pain mechanisms. Increasingly, studies suggest that the presence of inflammatory mediators can be measured systemically in the blood. These biomarkers may serve as novel tools for directing patient care. Currently, patient response to treatment is unpredictable with a significant rate of recurrence, and, while surgical treatments may provide anatomical correction and pain relief, they are invasive and costly. The review covers studies performed on populations with specific diagnoses and undefined origins of LBP. Since the natural history of LBP is progressive, the temporal nature of studies is categorized by duration of symptomology/disease. Related studies on changes in biomarkers with treatment are also reviewed. Ultimately, diagnostic biomarkers of LBP and spinal degeneration have the potential to shepherd an era of individualized spine medicine for personalized therapeutics in the treatment of LBP.
Abstract Background context Deep surgical site infections (SSIs) following spinal surgery are a significant burden to the patient, patient's family, and the health-care system. Because of increasing ...pressures to reduce SSIs and control costs, some spine surgeons have begun placing lyophilized vancomycin powder directly into the surgical wound at the conclusion of the procedure. However, the literature supporting this practice remains limited. Purpose To review the current literature examining the use of prophylactic intrasite vancomycin powder to control SSIs in spinal surgery and determine if any standard recommendations can be made. Study design A systematic review. Methods Ovid Medline and PubMed were searched to identify English language articles. Results No current guidelines are available for the use of intrasite vancomycin powder in preventing SSIs, and no standard dosage for the drug exists. Based on the limited literature and evidence currently available, there appears to be a protective effect of intrasite vancomycin powder on the incidence of SSI, without evidence of side effects. However, case reports do exist describing the systemic side effects after intrasite vancomycin powder during spine surgery. Conclusions The interpretation of the available evidence supporting the use of intrasite vancomycin powder in surgical wounds is limited, and its extrapolation should be performed with caution. Despite the lack of significant high-quality evidence available in the literature, many surgeons have adopted this practice; anecdotally, it continues to provide protection from infection without apparent significant risk of side effects.
Management of Osteoporosis in Spine Surgery Lehman, Ronald A; Kang, Daniel Gene; Wagner, Scott Cameron
Journal of the American Academy of Orthopaedic Surgeons,
2015-April, Letnik:
23, Številka:
4
Journal Article
Recenzirano
Osteoporosis is a burgeoning clinical problem that is characterized by decreased bone strength and density. It predisposes patients to fragility fractures and debilitating spine deformities. Several ...complications are associated with spine surgery in patients with osteoporosis, and there is currently no treatment algorithm to guide the spine surgeon. A multidisciplinary approach to treatment of patients with osteoporosis and spine deformity or fracture is encouraged, and preoperative planning is crucial for successful surgical outcomes. Several surgical techniques have been developed to treat osteoporosis-related deformities, including posterior instrumentation with fusion. However, achieving fixation and fusion in these patients can be difficult secondary to poor bone stock. Augmentation methods to improve pedicle screw fixation have evolved, including instrumentation at multiple levels, bioactive cement augmentation, and fenestrated or expandable pedicle screws, but their impact on clinical outcomes remains unknown. Management of osteoporosis in patients undergoing spine surgery is challenging, but with appropriate patient selection, medical optimization, and surgical techniques, these patients can experience pain relief, deformity correction, and improved function.
Abstract
Image guidance (IG) and robotics systems are becoming more widespread in their utilization and can be invaluable intraoperative adjuncts during spine surgery. Both are highly reliant upon ...stereotaxy and either pre- or intraoperative radiographic imaging. While user-operated IG systems have been commercially available longer and subsequently are more widely utilized across centers, robotics systems provide unique theoretical advantages over freehand and IG techniques for placing instrumentation within the spine. While there is a growing plethora of data showing that IG and robotic systems decrease the incidence of malpositioned screws, less is known about their impact on clinical outcomes. Both robotics and IG may be of particular value in cases of substantial deformity or complex anatomy. Indications for the use of these systems continue to expand with an increasing body of literature justifying their use in not only guiding thoracolumbar pedicle screw placement, but also in cases of cervical and pelvic instrumentation as well as spinal tumor resection. Both techniques also offer the potential benefit of reducing occupational exposures to ionizing radiation for the operating room staff, the surgeon, and the patient. As the use of IG and robotics in spine surgery continues to expand, these systems’ value in improving surgical accuracy and clinical outcomes must be weighed against concerns over cost and workflow. As newer systems incorporating both real-time IG and robotics become more utilized, further research is necessary to better elucidate situations where these systems may be particularly beneficial in spine surgery.
Abstract Background context Transforaminal lumbar interbody fusion (TLIF) is increasingly popular for the surgical treatment of degenerative lumbar disease. The optimal construct for segmental ...stability remains unknown. Purpose To compare the stability of fusion constructs using standard (C) and crescent-shaped (CC) polyetheretherketone TLIF cages with unilateral (UPS) or bilateral (BPS) posterior instrumentation. Study design Five TLIF fusion constructs were compared using finite element (FE) analysis. Methods A previously validated L3–L5 FE model was modified to simulate decompression and fusion at L4–L5. This model was used to analyze the biomechanics of various unilateral and bilateral TLIF constructs. The inferior surface of the L5 vertebra remained immobilized throughout the load simulation, and a bending moment of 10 Nm was applied on the L3 vertebra to recreate flexion, extension, lateral bending, and axial rotation. Various biomechanical parameters were evaluated for intact and implanted models in all loading planes. Results All reconstructive conditions displayed decreased motion at L4–L5. Bilateral posterior fixation conferred greater stability when compared with unilateral fixation in left lateral bending. More than 50% of intact motion remained in the left lateral bending with unilateral posterior fixation compared with less than 10% when bilateral pedicle screw fixation was used. Posterior implant stresses for unilateral fixation were six times greater in flexion and up to four times greater in left lateral bending compared with bilateral fixation. No effects on segmental stability or posterior implant stresses were found. An obliquely-placed, single standard cage generated the lowest cage-end plate stress. Conclusions Transforaminal lumbar interbody fusion augmentation with bilateral posterior fixation increases fusion construct stability and decreases posterior instrumentation stress. The shape or number of interbody implants does not appear to impact the segmental stability when bilateral pedicle screws are used. Increased posterior instrumentation stresses were observed in all loading modes with unilateral pedicle screw/rod fixation, which may theoretically accelerate implant loosening or increase the risk of construct failure.
The typically accepted surgical procedure for cervical disc pathology has been the anterior cervical discectomy and fusion (ACDF), although recent trials have demonstrated equivalent or improved ...outcomes with cervical disc arthroplasty (CDA). Trends for these two procedures regarding utilization, revision procedures, and other demographic information have not been sufficiently explored.
The present study aims to provide data regarding ACDF and CDA from 2006 to 2013 in the United States.
The present study is a retrospective national database analysis.
The present study included 20% sample of discharges from US hospitals, which is weighted to provide national estimates.
Functional measures such as national incidence, hospital costs, length of stay (LOS), routine discharge, revision burden, and patient characteristics were used in the present study.
Patients from the National Inpatient Sample (NIS) database who underwent primary ACDF, revision ACDF, primary CDA, and revision CDA from 2006 to 2013 were included. Demographic and economic data for the procedures' respective International Classification of Diseases, Ninth Revision, Clinical Modification codes were collected.
A total of 1,059,403 ACDF and 13,099 CDA surgeries were performed in the United States from 2006 to 2013. The annual number of ACDF increased by 5.7% nonlinearly from 120,617 in 2006 to 127,500 in 2013 (mean per year 132,425; range 120,617–147,966); CDA increased by 190% nonlinearly from 540 in 2006 to 1,565 in 2013 (mean per year 1,637; range 540–2,381). Cervical disc arthroplasty patients were younger and had more private or “other” insurance, including worker's compensation (p<.0001). Mean LOS was longer for ACDF (ACDF 2.3 days vs. CDA 1.5; p<.0001). Routine discharge was higher in the CDA group (CDA 96% vs. ACDF 89%; p-value<.0001). The mean hospital-related cost was more expensive for ACDF (ACDF $16,178 vs. CDA $13,197; p-value=.0007). Cervical disc arthroplasty mean revision burden, defined as the ratio of revision procedures to the sum of primary and revision procedures, was greater (CDA 5.9% vs. ACDF 2.3%, p-value=.01).
Nationally approximately 132,000 ACDFs are done each year compared with only 1,600 CDAs. The number of ACDF surgeries performed far outpaces CDA by a ratio of 81:1 in the United States without a clear direction in the trend for utilization given recent fluctuations. Cervical disc arthroplasty revision burden was more than double compared with the ACDF revision burden (5.9% vs. 2.3%), which was not accounted for by patient baseline demographics. The etiologies of these findings are likely multifactorial and require further research.
Osteolysis after cervical disc arthroplasty Joaquim, Andrei Fernandes; Lee, Nathan J.; Lehman, Ronald A. ...
European spine journal,
11/2020, Letnik:
29, Številka:
11
Journal Article
Recenzirano
Purpose
Cervical disc arthroplasty (CDA) has become an increasingly popular treatment for cervical degenerative disc disease. One potential complication is osteolysis. However, current literature on ...this topic appears limited. The purpose of this study is to elucidate the incidence, aetiology, consequence, and subsequent treatment of this complication.
Methods
A systematic literature review was performed according to the PRISMA guidelines. Studies discussing the causes, incidence and management of osteolysis after a CA were included.
Results
A total of nine studies were included. We divided these studies into two groups: (1) large case series in which an active radiological evaluation for osteolysis was performed (total = six studies), (2) case report studies, which discussed symptomatic cases of osteolysis (total = three). The incidence of asymptomatic osteolysis ranged from 8 to 64%; however, only one study reported an incidence of < 10% and when this case was excluded the incidence ranged from 44 to 64%. Severe asymptomatic bone loss (exposure of the implant) was found in less than 4% of patients. Bone loss from osteolysis appeared to occur early (< 1 year) after surgery and late (> 1 year) as well. Symptomatic patients with osteolysis often required revision surgery. These patients required removal of implant and conversion to fusion in the majority of the cases.
Conclusions
Osteolysis after CDA is common; however, the majority of cases have only mild or asymptomatic presentations that do not require revision surgery. The timing of osteolysis varies significantly. This may be due to differences in the aetiology of osteolysis.
We define here “temporal environmental hysteresis” as the time lag between when a pollutant's input to the environment stops and when its concentration in the environment drops to some desired ...fraction of its maximum concentration. The goal of this paper is to investigate temporal environmental hysteresis for polybrominated diphenyl ethers (PBDEs), which were widely used as flame retardants in consumer goods. These compounds were taken off the North American market in two steps: At the end of 2004, the so-called Penta-BDE and Octa-BDE products were withdrawn, and at the end of 2013, the Deca-BDE product was also discontinued. We focus here on PBDE concentrations in about 700 atmospheric samples collected every 12 days from 2005 to 2018 (inclusive) at two urban sites: Chicago, Illinois, and Cleveland, Ohio. In Chicago, the concentrations of BDE-47 and 99 decreased by a factor of two every 5.9 ± 0.9 and 8.0 ± 1.4 years, respectively, but the concentrations of BDE-209 doubled every 7.6 ± 1.8 years. In Cleveland, the concentrations of BDE-47 and 99 decreased by a factor of two every 5.1 ± 0.4 and 5.7 ± 0.5 years, respectively, and the concentrations of BDE-209 decreased by a factor of two every 9.2 ± 1.6 years. The delay in all these environmental responses relative to when these compounds were removed from the market is a result of decadal scale environmental hysteresis.
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•Temporal environmental hysteresis is the time it takes for a pollutant's concentrations to return to near zero.•For most persistent organic pollutants, temporal hysteresis is on the order of decades.•PBDE concentrations in Chicago's and Cleveland's air were investigated over the period 2005–2018.•Atmospheric concentrations of PBDE flame retardants in Chicago and Cleveland are decreasing slowly.
BACKGROUND:Spinopelvic fixation is an integral part of achieving solid fusion across the lumbosacral junction, especially in deformity procedures requiring substantial correction or long-segment ...constructs. Traditional S2-alar-iliac (S2AI) screw-placement techniques utilize fluoroscopy, increasing operative time and radiation exposure to the patient and surgeon. We describe a novel free-hand technique for S2AI screw placement in patients with adult spinal deformity.
METHODS:We reviewed the records of 45 consecutive patients who underwent spinopelvic fixation performed with use of S2AI screws by the senior surgeon and various fellows or residents over a 12-month period (2015 to 2016). In each case, the S2AI screws were placed utilizing a free-hand technique without fluoroscopic or image guidance. Screw position and accuracy were assessed by intraoperative O-arm imaging and analyzed using 3-dimensional interactive manipulation of computed tomography images.
RESULTS:A total of 100 screws were placed, 51 by the senior surgeon and 49 by trainees. The mean patient age was 57.4 ± 12.7 years at the time of surgery; 37 (82.2%) of the patients were female. Preoperative diagnoses included adult idiopathic scoliosis (n = 19), adult degenerative scoliosis (n = 15), flatback syndrome (n = 2), fixed sagittal imbalance (n = 6), and distal junctional kyphosis (n = 3). Five (5%) of the screws were placed with moderate to severe cortical breaches, all of which perforated the pelvis posteriorly, with no clinically notable neurovascular or visceral complications. The breach rate did not differ significantly between the senior surgeon and trainees.
CONCLUSIONS:The free-hand technique for S2AI screw placement, when performed in a standardized manner, was demonstrated to be safe and reliable in constructs requiring spinopelvic fixation. The accuracy of screw placement relies on visible and palpable anatomic landmarks that obviate the need for intraoperative fluoroscopy or image guidance, potentially reducing operative time and radiation exposure.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
A new proposed classification system for thoracolumbar (TL) spine injuries, including injury severity assessment, designed to assist in clinical management.
To devise a practical, yet comprehensive, ...classification system for TL injuries that assists in clinical decision-making in terms of the need for operative versus nonoperative care and surgical treatment approach in unstable injury patterns.
The most appropriate classification of traumatic TL spine injuries remains controversial. Systems currently in use can be cumbersome and difficult to apply. None of the published classification schemata is constructed to aid with decisions in clinical management.
Clinical spine trauma specialists from a variety of institutions around the world were canvassed with respect to information they deemed pivotal in the communication of TL spine trauma and the clinical decision-making process. Traditional injury patterns were reviewed and reconsidered in light of these essential characteristics. An initial validation process to determine the reliability and validity of an earlier version of this system was also undertaken.
A new classification system called the Thoracolumbar Injury Classification and Severity Score (TLICS) was devised based on three injury characteristics: 1) morphology of injury determined by radiographic appearance, 2) integrity of the posterior ligamentous complex, and 3) neurologic status of the patient. A composite injury severity score was calculated from these characteristics stratifying patients into surgical and nonsurgical treatment groups. Finally, a methodology was developed to determine the optimum operative approach for surgical injury patterns.
Although there will always be limitations to any cataloging system, the TLICS reflects accepted features cited in the literature important in predicting spinal stability, future deformity, and progressive neurologic compromise. This classification system is intended to be easy to apply and to facilitate clinical decision-making as a practical alternative to cumbersome classification systems already in use. The TLICS may improve communication between spine trauma physicians and the education of residents and fellows. Further studies are underway to determine the reliability and validity of this tool.
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