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Objective\ud To investigate whether early changes in fear of movement (kinesiophobia), self-efficacy and catastrophizing were mediators of the relationship between allocation to the pre-habilitation intervention and later changes in health outcomes.\ud \ud Methods\ud The original pre-habilitation trial (PREPARE, ISRCTN17115599) recruited 118 participants awaiting lumbar fusion surgery, half of whom received a prehabilitation intervention designed based on the modified fear-avoidance model and half of whom received usual care. Mediation analysis was performed to test each mediator separately. Analysis was performed on each outcome of interest separately (Oswestry disability index, patient-specific function, EQ general health and moderate/vigorous physical activity). Mediation analysis was carried out using PROCESS. Beta coefficients and bootstrapped 95% CIs were used to interpret the results.\ud \ud Results\ud None of the potential mediators was found to mediate the relationship between allocation to the intervention and 3-month scores on any of the health outcomes tested.\ud \ud Conclusions\ud Screening patients for higher levels of catastrophizing and fear avoidance and lower levels of self-efficacy could help ensure only the patients who are most likely to benefit from the intervention are included.\ud \ud Significance\ud Prehabilitation interventions for spinal fusion surgery have been found to improve health outcomes for patients. Theory-based interventions that target key mechanisms are more effective at improving outcomes than non-theory-based interventions. While no mediating effects were found for this particular intervention, the analysis suggests that the underlying theoretical model and treatment targets are appropriate and could drive improvement if more strongly targeted.

Study Design.This was a dual-center study over an eight-year period on patients undergoing single level fusion surgery with either posterior- (PLIF) or transforaminal lumbar interbody fusion (TLIF). We analyzed prospectively collected pre- and postoperative data from the national Danish surgical spine database (DaneSpine).Objective.The aim of this study was to compare clinical and patient-reported outcome (PRO) 2 years after TLIF or PLIF in patients with symptomatic lumbar mechanical disc degeneration.Summary of Background Data.PLIF and TLIF are well-described techniques for treating lumbar mechanical disc degeneration but whether the theoretical differences between the two techniques translate to different clinical outcomes is unknown.Methods.The primary outcome was Oswestry Disability Index (ODI) score at 2-year follow-up. Secondary outcome measures were scores on the European Quality of Life-5 Dimensions (EQ-5D) and visual analog scale (VAS) and the rate of intraoperative complications. To minimize baseline differences between the groups, propensity-score matching was employed in a 1:1 fashion, balancing the groups on preoperative factors including age, sex, back and leg pain, ODI, EQ-5D, and previous spine surgery.Result.The matched cohort included 211 patients in each cohort. There was no significant difference between the groups in the mean score on the ODI at two years (PLIF: 33 ± 20 vs. TLIF: 35 ± 20, P = 0.328). We found no statistically significant differences in EQ-5D score (0.54 ± 0.35 vs. 0.51 ± 0.34, P = 0.327), VAS score for back pain (47 ± 32 vs. 48 ± 29, P = 0.570) or leg pain (42 ± 33 vs. 41 ± 32, P = 0.936) between the PLIF and TLIF groups, respectively, at 2-year follow-up. Dural tears occurred in 9.5% in the PLIF group and 1.9% in the TLIF group (P = 0.002) corresponding to a relative risk of 5.0 (95% CI 1.7-14.4).Conclusion.We found no significant difference in PRO at 2-year follow-up between PLIF and TLIF for the treatment of lumbar disc degeneration. PLIF is associated with a five times higher risk of dural tears.Level of Evidence: 3.

Introduction. - Lumbar disc herniation is most common degenerative alteration of the spine. Whenever surgical therapy proves to be necessary, recurrent disc herniation is most frequent concern. Here, primary aim was to determine the percentage of patients eligible for insertion of an annular closure device (ACD). Secondary aim to evaluate 12 -month incidence of recurrent disc herniation at the operated level. Our hypothesis was that ACD might help in preventing recurrent disc herniation. Methods. - Patients in a single Swiss neurosurgical center underwent limited discectomy alone (n = 41, group 1) versus limited discectomy plus ACD (n = 12, group 2). Mean postoperative follow-up period was 12 months. Results. - Twelve out of 53 patients (22.6%) were eligible for ACD implantation. Patients of group 2 were significantly taller (mean 176 cm, 13= 0.007) as compared with group 1 (mean 170). The only statistically significant difference of intraoperative parameters between group 1 and 2 was amount of nucleus materiel removed (A= 0.01), being greater in group 2 (mean 0.9) as compared with group I (mean 0.3). In group 1 six patients (6/41, 14.6%) presented with symptomatic reherniation at same level of surgery, while in group 2 only one patient experienced recurrence (1/12, 8.3%). No adverse events were reported. Discussion. - In the current study one out of five patients with lumbar disc herniation was considered suitable for ACD placement. In vast majority of these patients reherniation was precluded on the short-term basis. Patients with ACD were taller and had intraoperatively a higher volume of the nucleus pulposus materiel removed. (C) 2022 Les Auteurs. Publie par Elsevier Masson SAS.

Objective To assess the long-term outcome and perioperative morbidity in spine surgeries for lumbar degenerative disorders and, thereby, to evaluate the safety of surgery in the aging population. Methods Retrospective study of patients aged > 70 years, operated for degenerative lumbar disorders between 2011 and 2015. We evaluated patient demographic, clinical and surgical data; comorbidities, perioperative complications, pre & postoperative pain scores and Oswestry disability index (ODI) scores, patient satisfaction and overall mortality. Results A total of 103 patients (Males: Females55:48) with mean age 74.6 years (70–85yrs) were studied. 60 patients (58.2%) had decompression alone, while 43 (41.8%) had decompression & fusion. Mean hospital stay was 5.7days. Mean follow-up was 47.6months (24–73mnths). Patients reported significant improvement in backpain (Numerical pain score 7.7 vs 1.6; p < 0.001), leg pain (Numerical pain score 7.4 vs 1.7; p < 0.001), disability (ODI 82.3 vs 19.1; p < 0.001) and walking distance (p < 0.001). 76% patients were satisfied with the results at the time of final follow-up. 26 patients (25.24%) had perioperative complications which were all minor, without mortality. Most common intraoperative & postoperative complications were dural tear (6.79%) & urinary tract infection (6.79%) respectively. Conclusions With meticulous perioperative care lumbar spine surgery is safe and effective in elderly population. Patients had longer mean hospital stay in view of the gradual and comprehensive rehabilitation program. Presence of comorbidities or minor perioperative complications did not increase the overall morbidity or affect the clinical outcomes of surgery in our study. Resumo Objetivos Avaliar o resultado no longo prazo e a morbidade perioperatória em cirurgias da coluna vertebral, devido a doenças lombares degenerativas e, assim, avaliar a segurança da cirurgia na população idosa. Métodos Estudo retrospectivo de pacientes com idade superior a 70 anos, submetidos à cirurgia em virtude de distúrbios lombares degenerativos, entre 2011 e 2015. Foram avaliados os dados demográficos, clínicos e cirúrgicos dos pacientes; comorbidades; complicações perioperatórias; escores de dor no pré e no pós-operatório; índice de incapacidade de Oswestry (ODI, na sigla em inglês); satisfação do paciente e a mortalidade geral. Resultados Foram estudados 103 pacientes (homens:mulheres, 55:48) com idade média de 74,6 anos (70 a 85 anos). 60 pacientes (58,2%) apresentaram somente descompressão, enquanto 43 (41,8%) apresentaram descompressão e fusão. O tempo médio de internação foi de 5,7 dias. O tempo médio de acompanhamento foi de 47,6 meses (24-73 meses). Os pacientes relataram melhora significativa da dor nas costas (pontuação numérica da dor 7,7 versus 1,6; p < 0,001), dor nas pernas (pontuação numérica da dor 7,4 versus 1,7; p < 0,001), incapacidade (ODI 82,3 versus 19,1; p < 0,001) e distância percorrida a pé (p < 0,001). Um total de 76% dos pacientes estavam satisfeitos com os resultados no momento do acompanhamento final. 26 pacientes (25,24%) apresentaram complicações perioperatórias, todas sem relevância e sem mortalidade. As complicações intra e pós-operatórias mais comuns foram ruptura dural (6,79%) e infecção do trato urinário (6,79%), respectivamente. Conclusões Com meticulosos cuidados perioperatórios, a cirurgia da coluna lombar é segura e eficaz na população idosa. Os pacientes tiveram um maior tempo médio de internação hospitalar, em virtude do programa de reabilitação gradual e abrangente. A presença de comorbidades ou complicações perioperatórias sem relevância, não aumentou a morbidade geral, nem afetou os resultados clínicos da cirurgia em nosso estudo.

Background: Physiotherapists (PTs) have an essential role in the facilitation of patients’ mobilization after lumbar spinal fusion (LSF). The aim of this study is to investigate whether PTs can predict one-year post-surgery outcome based on their first meeting with the patient immediately after LSF. Method: A prospective cohort study with one-year follow-up was conducted. In the first days after surgery, the PTs from hospital wards were asked to predict the patients’ overall LSF outcome one year after surgery. One year after surgery, the patients received a questionnaire including the Oswestry Disability Index (ODI), visual analogue scales (VAS) for leg and back pain, quality of life survey (EQ-5D-3 L), global perceived effect (GPA), and satisfaction with surgery outcome (SSO). Univariate and logistic regression were used to calculate the associations between the prognosis and predictive values. Results: The study included 170 patients. The analyses showed a significant association between the PTs’ prognosis and the primary outcome ODI (p 2 ≤ 0.09). There was no significant association between the PTs’ prognosis and the patients’ SSO (p = .17; R 2 = 0.01). Conclusion: There were significant associations between the PTs’ prognosis and disability, pain, health-related quality of life and global perceived effect one-year post-surgery, although the associations had low predictive values. There was no significant association between the PTs’ prognosis and patients’ SSO after one year. The PTs’ prognosis should not be used as a single component in further rehabilitation planning.

STUDY DESIGN: Propensity-matched retrospective study of patients prospectively enrolled in Danespine.OBJECTIVE: The aim of this study was to report 5-year patient reported outcome in lumbar spinal stenosis (LSS) patients who underwent wide laminectomy (WL), segmental bilateral laminotomies (SBL), or unilateral hemilaminectomy (UHL) with bilateral decompression.SUMMARY OF BACKGROUND DATA: The optimal procedure for LSS remains controversial. Studies have shown no difference in short term outcomes among micro-laminectomy, hemi-laminotomies, broad laminectomy, and laminectomy with instrumented fusion.METHODS: Patients with spinal stenosis who were enrolled in DaneSpine at two spine centers from January 2010 until May 2014 and underwent WL0, SBL, or UHL with bilateral decompression were identified. Patients completed standard questionnaires preoperatively and 1, 2, and 5 years after surgery. Patients in the three cohorts were propensity-matched using age, sex, body mass index (BMI), smoking status, number of surgical levels, American Society of Anesthesiologists (ASA) score, and patient-reported outcome measures (PROMs).RESULTS: Propensity matching produced 62 cases in each group. There were no differences in PROM among the three cohorts at five years follow up. Twelve patients were re-operated at the index level. The most frequent indication of reoperation was repeat decompression after SBL. Regression analysis revealed no statistical significant associations between the incidence of reoperation and age, sex, number of operated levels, ASA score, BMI, center, smoking status, or having a dural tear at index operation.CONCLUSION: This study revealed no significant difference PROMs, reoperation rates or time to reoperation at five years follow up between SBLs, UHL, or WL in patients operated for central LSS.Level of Evidence: 4.

Due to the aging society, the incidence of pyogenic spondylodiscitis is still rising. Although surgical treatment for spondylodiscitis in general is increasingly accepted, an optimal surgical strategy for treatment of pyogenic spinal infection has not yet been established. The aim of this study was to investigate the suitability of percutaneous posterior pedicle screw fixation for surgical treatment in patients with spondylodiscitis of the thoracolumbar spine. We conducted a retrospective review of a consecutive cohort of patients undergoing surgical treatment for spondylodiscitis of the thoracolumbar spine between January 2017 and December 2019. We assessed intraoperative and clinical data, comparing for the classic open and the percutaneous approach. In total, we analyzed 125 cases (39 female, 86 male). The mean age was 69.49 years ± 12.63 years. Forty-seven (37.6%) patients were operated on by a percutaneous approach for pedicle screw fixation, and 78 (62.4%) received open surgery. There was no significant difference in the mean age of patients between both groups (p= 0.57). The time of surgery for percutaneous fixation was statistically significantly shorter (p= 0.03). Furthermore, the estimated intraoperative blood loss was significantly lower in the minimally invasive group (p < 0.001). No significant difference could be observed regarding the recurrence rate of spondylodiscitis and the occurrence of surgical site infections (p= 0.2 and 0.5, respectively). Percutaneous posterior pedicle screw fixation appears to be a feasible option for the surgical treatment of a selected patient group with spondylodiscitis of the thoracic and lumbar spine.

Background Prehabilitation programs have led to improved postoperative outcomes in several surgical contexts, but there are presently no guidelines for the prehabilitation phase before lumbar fusion surgery. Objective The objective was to investigate whether a person-centered physical therapy prehabilitation program, based on a cognitive-behavioral approach, is more effective than conventional care in reducing disability and improving functioning after lumbar fusion surgery in patients with degenerative disk disease. Design This study was a randomized controlled trial. Setting The study took place at 2 private spine clinics and 1 university hospital. Patients We prospectively enrolled 118 patients scheduled for lumbar fusion surgery. Intervention The active intervention used a person-centered perspective and focused on promoting physical activity and targeting psychological risk factors before surgery. The control group received conventional preoperative care. Measurements The primary outcome was the Oswestry Disability Index score. Secondary outcomes were back and leg pain intensity, catastrophizing, kinesiophobia, self-efficacy, anxiety, depression, health-related quality of life, and patient-specific functioning, physical activity, and physical capacity. Data were collected on 6 occasions up to 6 months postoperatively. A linear mixed model was used to analyze the change scores of each outcome. Results No statistically significant between-group difference was found on the primary outcome (disability) over time (baseline to 6 months). Among secondary outcome measures, a statistically significant interaction effect (“Group × Time”) was seen for the European Quality of Life 5 Dimensions Questionnaire. The largest between-group difference on the European Quality of Life 5 Dimensions Questionnaire index was seen 1 week prior to surgery and favored the active intervention. The largest between-group effect sizes at the 6-month follow-up favored the active intervention, and were seen for physical activity intensity, steps per day, and the One Leg Stand Test. Both groups reached the minimal important change for the primary outcome and, in several secondary outcomes (pain intensity, back and leg; pain catastrophizing; anxiety; health-related quality of life [EQ5D VAS]), already at 8-week follow-up. Limitations The participants’ preoperative level of disability was lower than normative values, which suggests selection bias. Conclusions Both interventions led to clinically important changes, but it is not clear what kind of prehabilitation program is the most effective.

Objective An increasing demographic aging of the general population results in a rising incidence of octogenarians and nonagenarians with spine disease. Patients older than 65 years represent the majority of patients with degenerative lumbar spine disease in our daily clinical routine. Surgical treatment is undertaken reluctantly because of an increased rate of comorbidities. We therefore assessed complication rates of lumbar decompression in regard to neurological outcome and medical conditions in patients age 80 years or older in a retrospective single-center series. Methods Data for 244 patients (124 female, 120 male; mean age, 83.1 ± 3 years; age range, 80–95 years) who underwent decompressive surgery for lumbar spinal stenosis or disc herniation between April 2007 and February 2016 were assessed retrospectively. Age at surgery, neurologic deficits (preoperative and postoperative), relevant medical comorbidities and previous lumbar decompression, intraoperative and postoperative complications (e.g., surgery-related, medical), duration of surgery, length of hospital stay, and rate of revision surgeries were recorded. Results Surgery was performed for lumbar stenosis (184 patients; 75.4%), lumbar disc herniation (13 patients; 5.3%) or both (47 patients; 19.3%). Seventy-six patients (31.3%) patients experienced preoperative neurologic deficits; 48 (63.2%) of these patients improved, 28 (36.8%) of them were unchanged after surgery, and none deteriorated. New transient, postoperative, neurologic deficits occurred in 6 patients (2.5%). All 55 (22.5%) intraoperative complications were mild to moderate, and no severe surgical complications occurred. Two hundred fifteen patients (88%) had relevant medical disorders. Nineteen (7.7%) postoperative medical complications were reported in 17 patients (7%), of which 14 (73.7%) were severe and 5 (26.3%) were mild (4 pulmonary embolisms, 6 pneumonias, 3 myocardial infarctions, 1 postoperative renal failure, 5 urinary tract infections). Medical complications that necessitated intensive care unit treatment and resulted in lethal outcome were seen in 2 patients (0.8%). Conclusion Despite their age, the vast majority of octogenarians and nonagenarians benefited from lumbar decompression surgery. Mild to moderate intraoperative complications were relatively frequent, whereas severe intraoperative complications did not occur. The majority of medical complications was severe, but the incidence was acceptable, and the postoperative outcome was still favorable in most patients.

Purpose: To summarize the recommendations from the national clinical guideline published by the Danish Health Authority regarding surgical and nonsurgical interventions in treatment of lumbar spinal stenosis in patients above the age of 65 years. Methods: A multidisciplinary working group formulated recommendations based on the GRADE approach. Results: Seven of the recommendations were based on randomized controlled trials and three on professional consensus. The guideline recommends surgical decompression for symptomatic lumbar spinal stenosis. Supervised exercise and postsurgical supervised exercise are recommended due to the general beneficial effects of training on general health, even though there was no evidence on an effect on neurogenic pain. The guideline does not recommend manual therapy, paracetamol, NSAIDs, opioids, neurogenic pain medication, muscle relaxants, and decompression combined with instrumented fusion as there was no evidence of the beneficial effect. Conclusion: The recommendations are based on low to very low quality of evidence or professional consensus as well as patient preferences and positive or harmful effects of the intervention. The true treatment effect may therefore be different from the estimated effects, which is why the results should be interpreted with caution. The working group recommends intensified research in relation to all aspects of management of lumbar spinal stenosis. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.].

OBJECTIVE: To investigate the predictive value of preoperative fear-avoidance factors (self-efficacy for exercise, pain catastrophizing, kinesiophobia, and depression), walking capacity, and traditional predictor variables for predicting postoperative changes in physical activity level and disability 6 months after lumbar fusion surgery in patients with chronic low back pain (LBP). METHODS: We prospectively enrolled 118 patients scheduled for lumbar fusion surgery for motion-elicited chronic LBP with degenerative changes in 1-3 segments of the lumbar spine. Associations between the predictors and the dependent variables were investigated with multiple linear regression analysis. Dependent variables were physical activity level as objectively measured with a triaxial accelerometer and disability as measured with the Oswestry Disability Index. RESULTS: Preoperative physical activity level (β = -0.349; P < 0.001) and self-efficacy for exercise (β = 0.176; P = 0.021) were significant predictors of the postoperative change in physical activity. Preoperative disability (β = -0.790; P < 0.001), self-efficacy for exercise (β = 0.152; P = 0.024), and pain catastrophizing (β = 0.383; P = 0.033) were significant predictors for the change in the Oswestry Disability Index. CONCLUSIONS: Patients with low levels of preoperative physical activity were more likely to increase their level of physical activity after lumbar fusion surgery, especially when their self-efficacy for exercise was high. However, most of these patients still had low levels of physical activity after surgery, and they may therefore need extra support in increasing their postoperative physical activity levels.

Study Design. A cross-sectional survey in the Netherlands and Sweden.Objective. To investigate Dutch and Swedish spinal surgeons' opinions on spinal fusion pre- and postoperative rehabilitation.Summary of Background Data. Lumbar spinal fusion surgery is increasingly provided in patients with chronic low back pain. No guidelines however exist for pre-and postoperative rehabilitation and it is unknown what opinions spinal surgeons currently have about pre-and postoperative rehabilitation.Methods. A survey was circulated to Dutch and Swedish spinal surgeons. Reminders were sent after 4 and 8/9 weeks. Data of completed questionnaires of orthopedic-and neurosurgeons currently performing lumbar spinal fusion were included for analysis. Analysis comprised a range of descriptive summaries (numerical, graphical, and tabular).Results. Surveys of 34 Dutch and 48 Swedish surgeons were analyzed. Surgeons provided preoperative information on postoperative mobilization. Spinal fusion techniques varied, but technique did not influence postoperative treatment. Swedish surgeons recommended slightly faster mobilization than Dutch (direct vs. 1-day postoperative), and more activities the first day (sitting, standing, walking). Stair climbing was the most reported discharge criterion; however, time point to start varied. More Swedish surgeons referred to postoperative physiotherapy than Dutch (88% vs. 44%). Time-point to start home activities varied from 1 week to more than 6 months. Pain increase was allowed for less than 24 hours (The Netherlands 81%, Sweden 92%).Conclusion. Findings reflect variability in lumbar spinal fusion rehabilitation in two European countries, especially in postoperative phase. The study proposes many new research topics and acts as starting point for future research valuable for the spinal community.

The Danish Health Authority has recently published a new guideline on the treatment of lumbar disc herniation with radiculopathy. This paper goes through the surgical treatment and considers the evidence behind surgical treatment of these patients, along with the outcome reported in literature. The new guideline recommends referring patients to be assessed by a surgeon within 12 weeks in cases, where severe and debilitating pain persists despite non-surgical treatment. This is found to be well in line with literature, as many studies have shown time to be a predictive factor in surgical treatment of these patients.

STUDY DESIGN Prospective observational cohort study. OBJECTIVE The aim of this study was to determine the long-term clinical results and prosthesis survival in patients treated with lumbar total disc replacement (TDR). SUMMARY OF BACKGROUND DATA Fusion has become the current standard surgical treatment for lumbar degenerative disease. TDR is an alternative treatment that seeks to avoid fusion-related adverse events, specifically adjacent segment disease. METHODS Sixty-eight consecutive patients treated with TDR from 2003 to 2008 were invited to follow-up and complete a Visual Analog Scale (VAS) for back and leg pain, the Dallas Pain Questionnaire (DPQ), and the Short Form-36. These surveys were also administered to the subjects before their index TDRs. Data on reoperation were collected from the patients' medical records. RESULTS Fifty-seven (84%) patients were available for follow-up at a mean 10.6 years post-operatively (range 8.1-12.6 years). There was a significant improvement from preop to latest follow-up in VAS (6.8 vs. 3.2, P

Objective: The Timed Up and Go (TUG) test is a simple, objective and standardized measure for objective functional impairment (OFI) in patients with lumbar degenerative disc disease (DDD). The objective of the current work was to validate the OFI baseline severity stratification (BSS). Methods: Data[for full text, please go to the a.m. URL], 68. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), 7. Joint Meeting mit der Society of British Neurological Surgeons (SBNS)

First introduced by Pimenta et al. in 2001, the extreme lateral interbody fusion (XLIF®) approach is a safe and effective alternative to anterior or posterior approaches to lumbar fusion, avoiding the large anterior vessels and posterior structures including the paraspinous muscles, facet joint complexes and tension bands. The authors provide a detailed description of the surgically relevant anatomy focusing on the close relationship among the lumbar plexus, psoas muscle and lateral spinal column. The surgical technique is detailed step by step, stressing how to avoid complications. A video clip of an XLIF is provided, and important perioperative considerations are listed in detail. The XLIF® approach is a safe procedure allowing an approach to the lateral lumbar spine. Nevertheless, the surgeon’s knowledge of anatomical landmarks, response to visual and tactile cues, and intraoperative decision-making skills remain of paramount importance. • Correct lateral positioning with an orthogonal orientation of the corresponding lumbar vertebral body is of key importance. • Subsequent table repositioning for every level is advised in multilevel cases. • Posterior structures including the paraspinous muscles, facet joint complexes and tension bands are mostly preserved. • Meticulous preoperative planning of the psoas docking point, considering all level-specific vascular and neuronal elements, is of paramount importance. • In general, concavity is recommended for the selection of the approach side. • A careful endplate and contralateral preparation and release are mandatory in order to allow bony fusion and maximum indirect foraminal decompression. • Using a perioperative dexamethasone bolus seems to be effective at the L4/5 level to reduce postoperative plexopathy. • Overdistraction should be avoided in order to prevent cage subsidence. • A major disadvantage is the relatively high, but mostly only transient, incidence of psoas weakness as well as hip-groin-thigh pain, dysaesthesia and/or numbness. • Major advantages include indirect neurological decompression, minimal blood loss, shorter operation times, decreased overall infection rates and more surface for bony fusion.

Die lumbale Diskushernie (LDH) ist ein Krankheitsbild mit hoher Prävalenz. Das grösste Risiko während des postoperativen Verlaufes ist das Risiko eines Diskushernienrezidivs mit einer Inzidenz, je nach Literaturangabe, von 1–18%. Aus der aktuellen Literatur geht hervor, dass ein grosser Anulus-Defekt und eine limitierte perioperative Bandscheibenfachausräumung zu einem erhöhten Risiko eines Diskushernienrezidivs führen. Im Gegensatz dazu ist eine grosszügige perioperative Ausräumung des Bandscheibenfachs mit einem beschleunigten postoperativen Verlust der Bandscheibenhöhe und damit mit einer zunehmenden Bandscheibendegeneration vergesellschaftet. Der Wirbelsäulenchirurg ist perioperativ bei jeder LDH-Operation mit dieser Problematik konfrontiert. Seit einiger Zeit wurden sogenannte Anulus-Verschluss-Produkte (engl. anular closure devices) mit dem Ziel entwickelt, das postoperative Rezidivrisiko zu senken. Die vorliegende Arbeit diskutiert anhand einer aktuellen Patientengeschichte die Position einer Anulus-Verschluss-Prothese in Bezug auf die Problematik Rezidivrisiko vs. postoperative Bandscheibendegeneration.

To evaluate whether anterior lumbar interbody fusion (ALIF) is superior to transforaminal lumbar interbody fusion (TLIF) in cases of post-discectomy syndrome (PDS).In this retrospective study, we analyzed the consecutive results of 83 patients operated for PDS refractory to conservative treatment. A total of 46 patients underwent ALIF via a retroperitoneal approach; 37 patients underwent TLIF. Both fusion types were augmented by means of pedicle screw instrumentation. Early and delayed complications were registered within the course of hospitalization or outpatient clinical follow-up, respectively. Parameters such as patient satisfaction, current pain levels, pain medication, and change in work ability were obtained via telephone follow-up.Overall, 81.9% of patients were available for follow-up. Both ALIF and TLIF significantly improved back and leg pain (p0.01) and were described as satisfying operations by 75.8% and 73.3% of the patients, respectively. No significant difference between ALIF and TLIF results could be observed. Complications included dural tears, screw malposition, bleeding from major vessels (ALIF), abdominal wall insufficiency (ALIF), and nerve root injury (TLIF). One patient in the ALIF group and seven patients in the TLIF group required fusion extensions to adjacent levels within the observation period (observation period was 34 and 71 months, respectively).Both ALIF and TLIF techniques can be applied for PDS with equally good results. The technical advantages of ALIF have to be balanced with the additional morbidity and operation time owed to the additional approach. ALIF might be associated with a lower incidence of adjacent level disease compared with TLIF.

OBJECTIVEEnhanced Recovery After Surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. Thanks to the improvement in care protocols and the fluidity of the patient pathway, the first goal of ERAS is the improvement of surgical outcomes and patient experience, with a final impact on a reduction in the hospital length of stay (LOS). The implementation of ERAS in spinal surgery is in the early stages. The authors report on their initial experience in applying an ERAS program to several degenerative spinal fusion procedures.METHODSThe authors selected two 2-year periods: the first from before any implementation of ERAS principles (pre-ERAS years 2012–2013) and the second corresponding to a period when the paradigm was applied widely (post-ERAS years 2016–2017). Patient groups in these periods were retrospectively compared according to three degenerative conditions requiring fusion: anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), and posterior lumbar fusion. Data were collected on patient demographics, operative and perioperative data, LOSs, 90-day readmissions, and morbidity. ERAS-trained nurses were involved to support patients at each pre-, intra-, and postoperative step with the help of a mobile application (app). A satisfaction survey was included in the app.RESULTSThe pre-ERAS group included 1563 patients (159 ALIF, 749 ACDF, and 655 posterior fusion), and the post-ERAS group included 1920 patients (202 ALIF, 612 ACDF, and 1106 posterior fusion). The mean LOS was significantly shorter in the post-ERAS group than in the pre-ERAS group for all three conditions. It was reduced from 6.06 ± 1.1 to 3.33 ± 0.8 days for the ALIF group (p < 0.001), from 3.08 ± 0.9 to 1.3 ± 0.7 days for the ACDF group (p < 0.001), and from 6.7 ± 4.8 to 4.8 ± 2.3 days for posterior fusion cases (p < 0.001). There was no significant difference in overall complications between the two periods for the ALIF (11.9% pre-ERAS vs 11.4% post-ERAS, p = 0.86) and ACDF (6.0% vs 8.2%, p = 0.12) cases, but they decreased significantly for lumbar fusions (14.8% vs 10.9%, p = 0.02). Regarding satisfaction with overall care among 808 available responses, 699 patients (86.5%) were satisfied or very satisfied, and regarding appreciation of the mobile e-health app in the perceived optimization of care management, 665 patients (82.3%) were satisfied or very satisfied.CONCLUSIONSThe introduction of the ERAS approach at the authors’ institution for spinal fusion for three studied conditions resulted in a significant decrease in LOS without causing increased postoperative complications. Patient satisfaction with overall management, upstream organization of hospitalization, and the use of e-health was high. According to the study results, which are consistent with those in other studies, the whole concept of ERAS (primarily reducing complications and pain, and then reducing LOS) seems applicable to spinal surgery.

Background The extreme lateral lumbar interbody fusion (XLIF) technique is safe and effective; however, the deep and tight surgical corridor makes visual identification of important landmark structures, as well as sufficient endplate and contralateral preparation, challenging. In the present study, we analyzed the safety and feasibility of endoscope-assisted (EA) XLIF procedures. Methods This was a retrospective single-center study on consecutive patients undergoing XLIF procedures between February 2014 and July 2016. EA-XLIF and conventional XLIF (c-XLIF) procedures were compared in terms of the duration of surgery, estimated blood loss (EBL), perioperative and postoperative complications, and postoperative outcomes. Results A total of 41 patients (mean age, 66.7 years ± 10.0 years; 22 males [53.7%]) underwent a XLIF procedure, including 6 (14.6%) who underwent EA-XLIF. EA-XLIF did not increase the duration of surgery or EBL. No perioperative or postoperative complications were observed in any of the EA-XLIF procedures. Clinical and radiologic outcomes at 6 weeks postsurgery and at the last follow-up (mean, 8.0 ± 5.8 months postsurgery) were similar for patients in the EA-XLIF and c-XLIF groups. The EA-XLIF technique was considered particularly helpful for checking the lumbar plexus anatomy on the psoas surface, identifying the relationship between the peritoneum and the psoas muscle, positioning the shim into the disc space, removing the disk, and checking the quality of contralateral release and endplate preparation. Conclusions The EA-XLIF technique is safe and may be considered as an adjunct procedure, offering improved visualization to guide the surgeon in key steps of the XLIF procedure.

BACKGROUND: Following lumbar fusion surgery, a successful outcome is empirically linked to effective rehabilitation. While rehabilitation is typically postoperative, the phase before surgery - termed prehabilitation - is reportedly an ideal time to prepare the patient. There are presently no guidelines for prehabilitation before lumbar fusion surgery. Physical activity has well-known health benefits, and staying physically active despite pain is a major principle in non-pharmacological chronic low back pain treatment. Psychological factors such as fear of movement, pain catastrophizing and low self-efficacy are known to be barriers to staying active. No studies have investigated prehabilitation protocols that promote physical activity and target psychological risk factors before lumbar fusion surgery. The aim of our proposed randomised controlled trial is to investigate whether patients who undergo lumbar fusion surgery for degenerative disc disease experience better functioning with a physiotherapeutic prehabilitation program (PREPARE) based on a cognitive behavioural approach compared to conventional care. METHODS/DESIGN: We will recruit 110 patients between 18-70 years of age with degenerative disc disease who are waiting for lumbar fusion surgery. These patients will be randomly assigned to receive either PREPARE or conventional care. PREPARE uses a person-centred perspective and focuses on promoting physical activity and targeting psychological risk factors before surgery. The primary outcome will be disability measured using the Oswestry Disability Index 2.0. Secondary outcomes will include functioning (patient-reported and performance-based), physical activity (accelerometer), health-related quality of life, back and leg pain intensity, pain catastrophizing, kinesiophobia, self-efficacy, depression, anxiety, satisfaction with treatment results and health economic factors. Data will be collected at baseline (preoperatively) after the intervention (preoperatively), 3 and 8 weeks, 3, 6, 12, 24 and 60 months postoperatively. DISCUSSION: We hypothesise that the focus on promoting physical activity and targeting psychological risk factors before surgery will decrease disability and help the patients to be more active despite pain both before and after surgery. We will use a combination of outcome measures both patient-reported and performance-based, as well as accelerometer data. This will provide a more comprehensive picture of the patient's functioning than just patient-reported outcomes alone. TRIAL REGISTRATION: Current Controlled Trials ISCRTN17115599 , Retrospectively Registered 18 May 2015.

SPECT fused with computed tomography (CT) provides a new approach for more accurate diagnosis of pseudathrosis after spinal fusion procedures. The aim of this study was to compare the findings of SPECT fused with CT (SPECT/CT) with those of CT alone for the diagnosis of pseudarthrosis.SPECT and CT of 10 consecutive patients with recurrence of back and/or leg pain and with suspicion of pseudarthrosis on conventional radiologic imaging were analyzed retrospectively. All had previously undergone anterior and/or posterior lumbar fusion techniques. Presence of screw loosening, nonunion through or around the cages, and facet joint degeneration were assessed for diagnosis of pseudarthrosis. Based on SPECT/CT scan findings, the decision of surgical reintervention was made on 6 of 10 patients. The clinical follow-up (mean, 15.6 months; range, 5-29 months) was evaluated according to Macnab criteria (excellent, good, fair, poor).All patients showing screw loosening on CT alone showed also an abnormal uptake on SPECT/CT. SPECT/CT did not show abnormal uptake in 3 of 5 patients who had nonunion through/around the cages on CT alone. SPECT/CT was able to show increased uptake in 6 cases in which CT alone did not show facet joint degeneration.In the lumbar spine, SPECT/CT seems to increase specificity for detection of nonunion of interbody devices compared with CT alone. It is more sensitive than CT to detect facet joint degeneration, and it can detect screw loosening as well as CT. These findings can be helpful for surgeons in planning appropriate surgical revision strategy.

OBJETIVO: estudo prospectivo para avaliar a utilizacao da cifoplastia e vertebroplastia como tecnicas complementares para o tratamento das fraturas osteoporoticas tipo compressao. METODOS: apos um mes de tratamento conservador, os pacientes com fratura osteoporotica do tipo compressao e com dor intratavel, foram submetidos a cifoplastia ou vertebroplastia de acordo com algoritmo que considera o tempo da fratura e a quantidade do colapso do corpo vertebral. Biopsia ossea foi obtida no intra-operatorio para excluir os pacientes com tumor ou osteomalacia. RESULTADOS: cento e trinta e quatro pacientes foram incluidos de acordo com os criterios do estudo. A media de idade foi 67,7 anos. O seguimento medio foi 33 meses. Dez pacientes nao foram seguidos e 154 atingiram um seguimento minimo de dois; 118 pacientes (69,5%) foram submetidos a vertebroplastia e 36 (30,5%) a cifoplastia. Ocorreram complicacoes em cinco pacientse tratados por verebroplastia, sendo que um paciente apresentou neuropatia intercostal transitoria e quatro pacientes fratura por compressao, tendo ocorrido na vertebra adjacente em dois pacientes. Nao foi observada diferenca nos escores da avaliacao da dor e do questionario de Oswestry. CONCLUSAO: apos um seguimento medio de tres anos foram observados resultados satisfatorios com a utilizacao da vertebroplastia ou cifoplastia para o tratamento das fraturas osteoporoticas por compressao. Ambas as tecnicas mostraram bons resultados, de acordo com a sua indicacao especifica.

Study Design. A cost-effectiveness analysis conducted alongside a randomized clinical trial. Objective. To assess the cost-effectiveness of a preoperative cognitive-behavioral therapy (CBT) intervention compared to usual care for patients undergoing lumbar spinal fusion surgery (LSF). Summary of Background Data. The clinical effectiveness of a preoperative CBT intervention for patients undergoing LSF has been investigated in a randomized clinical trial. Economic evaluation is however essential for decision makers to make informed choices regarding allocation of scarce resources. Methods. 90 patients undergoing LSF were randomly allocated to usual care (control group) or usual care plus a preoperative CBT intervention (CBT group). Outcome parameters included quality-adjusted life years (QALY), based on the EQ-5D, and pain-related disability, based on the Oswestry disability index (ODI). Health care use and productivity loss were estimated from national registers. Results. One year after LSF the estimated QALY was significantly better for the CBT group with 0.710 (95% CI 0.670; 0.749) versus 0.636 (95% CI 0.5573; 0.687). For the ODI, the CBT group reported significantly larger disability reductions at 3 months (P =0.003) and 6 months (P =0.047), but not at 1 year (P=0.082).There was no difference in the overall costs of the two groups (-s89 (95% CI-12,080; 11,902)), leading to a 70% probability of the CBT intervention being cost-effective at a willingness-to-pay of s40,000 for one additional QALY. For an additional gain of 15 ODI points the probability was 90% at a threshold of s10,000. These results remained largely unaffected by relevant sensitivity analyses, confirming the robustness of findings. Conclusion. Preoperative CBT appears to be more effective and cost neutral when considering the overall health care sector and labor market perspective, supporting the implementation of preoperative CBT in the course of treatment for LSF surgery in a Danish context.

Because of significant complications related to the use of autologous bone grafts in spinal fusion surgery, bone substitutes and growth factors such as bone morphogenetic protein (BMP) have been developed. One of them, recombinant human (rh) BMP-2, has been approved by the Food and Drug Administration (FDA) for use under precise conditions. However, rhBMP-2-related side effects have been reported, used in FDA-approved procedures, but also in off-label use.A systematic review of clinical data was conducted to analyse the rhBMP-2-related adverse events (AEs), in order to assess their prevalence and the associated surgery practices. Medline search with keywords “bone morphogenetic protein 2”, “lumbar spine”, “anterolateral interbody fusion” (ALIF) and the filter “clinical trial”. FDA published reports were also included. Study assessment was made by authors (experienced spine surgeons), based on quality of study designs and level of evidence. Extensive review of randomised controlled trials (RCTs) and controlled series published up to the present point, reveal no evidence of a significant increase of AEs related to rhBMP-2 use during ALIF surgeries, provided that it is used following FDA guidelines. Two additional RCTs performed with rhBMP-2 in combination with allogenic bone dowels reported increased bone remodelling in BMP-treated patients. This AE was transient and had no consequence on the clinical outcome of the patients. No other BMP-related AEs were reported in these studies. This literature review confirms that the use of rhBMP-2 following FDA-approved recommendations (i.e. one-level ALIF surgery with an LT-cage) is safe. The rate of complications is low and the AEs had been identified by the FDA during the pre-marketing clinical trials. The clinical efficiency of rhBMP-2 is equal or superior to that of allogenic or autologous bone graft in respect to fusion rate, low back pain disability, patient satisfaction and rate of re-operations. For all other off-label use, the safety and effectiveness of rhBMP-2 have not been established, and further RCTs with high level of evidence are required.

STUDY DESIGN: A prospective, randomized, clinical study with a 2-year follow-up.OBJECTIVES: To analyze the effect of three different rehabilitation strategies for lumbar spinal fusion patients.SUMMARY OF BACKGROUND DATA: Fifteen percent to 40% of lumbar spinal fusion patients are not expected to improve significantly over a 2-year period. Optimization of present forms of rehabilitation could possibly further improve the outcome.MATERIALS AND METHODS: Between 1996 and 1999, 90 patients who had undergone lumbar spinal fusion were 3 months after surgery randomized to one of three different rehabilitation groups. Video group participants watched a video of exercises for training and were subsequently and only once provided instruction regarding their use. The back-café group was provided the same program as the video group, but as a supplement met with a back-café with other fusion-operated patients three times over an 8-week period. The training group was provided physical therapy training twice weekly for 8 weeks. Functional outcome was evaluated at 6, 12, and 24 months after surgery by use of the low back pain rating scale and a questionnaire covering daily functions, work status, and a patient's contact with the primary sector.RESULTS: By 2-year follow-up, the back-café and video groups had less pain compared with the training group (P < 0.03). The back-café group was better at performing daily functions such as carrying bags of market items (P < 0.01), getting up from a chair (P < 0.01), and ascending staircases (P < 0.01) compared with the video and training groups. More in the back-café group resumed working after surgery compared with the two other groups (P < 0.04). The video group had significantly more contacts with general practitioners, physical therapists, and so on compared with the back-café and training groups (P < 0.001).CONCLUSION: The patients in the back-café group were significantly better at accomplishing a succession of daily tasks compared with the video and training groups 2 years after lumbar spinal fusion. At the 2-year follow-up the training group had a significant pain problem compared with the video and back-café groups. The video group had significantly more treatment demands outside the hospital system. This study demonstrates the relevance of the inclusion of coping schemes and questions the role of intensive exercises in a rehabilitation program for spinal fusion patients.

Purpose: Explore the relationships between preoperative findings and clinical outcome following lumbar disc surgery, and investigate the prognostic value of physical examination findings after accounting for information acquired from the clinical history.METHODS:We recruited 55 adult patients scheduled for first time, single-level lumbar discectomy. Participants underwent a standardized preoperative evaluation including real-time ultrasound imaging assessment of lumbar multifidus function, and an 8-week postoperative rehabilitation programme. Clinical outcome was defined by change in disability, and leg and low back pain (LBP) intensity at 10 weeks. Linear regression models were used to identify univariate and multivariate predictors of outcome.RESULTS:Univariate predictors of better outcome varied depending on the outcome measure. Clinical history predictors included a greater proportion of leg pain to LBP, pain medication use, greater time to surgery, and no history of previous physical or injection therapy. Physical examination predictors were a positive straight or cross straight leg raise test, diminished lower extremity strength, sensation or reflexes, and the presence of postural abnormality or pain peripheralization. Preoperative pain peripheralization remained a significant predictor of improved disability (p = 0.04) and LBP (p = 0.02) after accounting for information from the clinical history. Preoperative lumbar multifidus function was not associated with clinical outcome.CONCLUSIONS:Information gleaned from the clinical history and physical examination helps to identify patients more likely to succeed with lumbar disc surgery. While this study helps to inform clinical practice, additional research confirming these results is required prior to confident clinical implementation. PURPOSE:Explore the relationships between preoperative findings and clinical outcome following lumbar disc surgery, and investigate the prognostic value of physical examination findings after accounting for information acquired from the clinical history.METHODS:We recruited 55 adult patients scheduled for first time, single-level lumbar discectomy. Participants underwent a standardized preoperative evaluation including real-time ultrasound imaging assessment of lumbar multifidus function, and an 8-week postoperative rehabilitation programme. Clinical outcome was defined by change in disability, and leg and low back pain (LBP) intensity at 10 weeks. Linear regression models were used to identify univariate and multivariate predictors of outcome.RESULTS:Univariate predictors of better outcome varied depending on the outcome measure. Clinical history predictors included a greater proportion of leg pain to LBP, pain medication use, greater time to surgery, and no history of previous physical or injection therapy. Physical examination predictors were a positive straight or cross straight leg raise test, diminished lower extremity strength, sensation or reflexes, and the presence of postural abnormality or pain peripheralization. Preoperative pain peripheralization remained a significant predictor of improved disability (p = 0.04) and LBP (p = 0.02) after accounting for information from the clinical history. Preoperative lumbar multifidus function was not associated with clinical outcome.CONCLUSIONS:Information gleaned from the clinical history and physical examination helps to identify patients more likely to succeed with lumbar disc surgery. While this study helps to inform clinical practice, additional research confirming these results is required prior to confident clinical implementation.

Objectives: We evaluated clinical and radiographic results of patients treated by the ProDisc II total disc prosthesis (TDP) for painful degenerative lumbar disc disease.Methods: The study included 34 patients (25 females, 9 males; mean age 44 years; range 37 to 54 years) who underwent a total of 62 lumbar TDP procedures for degenerative lumbar disc disease. Lumbar disc replacement involved one level in 12 cases, two levels in 17 cases, three levels in four cases, and four levels in one case. Clinical and radiographic assessments were made preoperatively and at 3, 6, 12, and 24 months postoperatively. Clinical evaluations were made with a visual analog scale (VAS) and the Oswestry Disability Index (ODI). Radiographic parameters included lumbar lordotic angle, the height and flexion-extension range of the affected discs. The mean follow-up period was 29.3 months (range 24 to 39 months).Results: Low back pain and lower extremity pain showed near-complete improvement up to the third postoperative month. At the end of the 24th month, preoperative ODI and VAS scores of 59.6 and 7.8 decreased to 19.8 and 1.0, respectively. Preoperative and postoperative lumbar lordotic angles were 52.6° and 57.1°, respectively. The mean disc height of implanted discs increased from 4.6 mm to 12.1 mm postoperatively. The mean flexion-extension angle increased from 2.8° to 8.4° at L5-S1, and from 2.6° to 9.8° at L4-5. The overall improvement in the mean flexion-extension angle was 7.2°. Conclusion: Lumbar disc prosthesis offers significant advantages in terms of functional improvement and increased quality of life in the surgical treatment of degenerative disc disease., Amaç: Ağrılı dejeneratif lomber disk hastalığı nedeniyle ProDisc II total disk protezi (TDP) uygulanan olguların klinik ve radyografik sonuçları değerlendirildi.Çalışma planı: Dejeneratif disk hastalığı (DDH) tanısıyla lumbar TDP uygulanan 34 hasta (25 kadın, 9 erkek; ort. yaş 44; dağılım 37-54) çalışmaya alındı. Toplam 62 TDP prosedürü olmak üzere, 12 olguya tek, 17 olguya iki, dört olguya üç, bir olguya ise dört seviyeli lomber TDP uygulandı. Olgular ameliyat öncesinde ve ameliyat sonrası 3, 6, 12, 24. aylarda klinik ve radyografik olarak değerlendirildi. Klinik değerlendirmede görsel analog skala (GAS) ve Oswestry Engellilik İndeksi (OEİ) kullanıldı. Radyografik değerlendirmede, lomber lordoz açısı, tutulan diskin yüksekliği ile fleksiyon-ekstansiyon açıları ölçüldü. Ortalama takip süresi 29.3 ay (dağılım 24-39 ay) idi. Sonuçlar: Olguların bel ve bacak ağrıları en geç üçüncü ayda tama yakın düzeldi. Klinik değerlendirmede, ameliyat öncesi 59.6 olan OEİ skoru ameliyat sonrası 24. ayda 19.8’e, GAS skoru ise 7.8’den 1.0’e geriledi. Lomber lordoz ameliyat öncesinde 52.6°, ameliyat sonrasında 57.1° olarak ölçüldü. Disk yüksekliği implantasyon yapılan seviyelerde 4.6 mm’den 12.1 mm’ye yükseldi. Fleksiyon-ekstansiyon açısı L5-S1 seviyesinde 2.8 dereceden 8.4 dereceye; L4-5 seviyesinde ise 2.6 dereceden 9.8 dereceye yükseldi. Total disk protezi uygulanan tüm disklerde fleksiyon-ekstansiyon açısında düzelme ortalama 7.2° bulundu. Çıkarımlar: Lomber disk protezi, dejeneratif disk hastalığının cerrahi tedavisinde hastaların fonksiyonları ve yaşam kalitelerinin sürdürülmesi açısından önemli avantajlara sahiptir.

Objectives: Different techniques and choices exist for revision of pedicle screws, two of which are pedicle screw combined with cement augmentation and expansive pedicle screw fixation. This biomechanical study was designed to compare the pullout strengths of two different revision techniques.Methods: Fourteen lumbar vertebrae obtained from four calves (mean age 15 months) were divided into two groups equal in number. Monoaxial 6.0-mm pedicle screws were inserted into the right pedicles, and axial pullout testing was performed at a rate of 10 mm/min and failure strengths were recorded. Revision was performed with the same-sized pedicle screws reinforced with polymethylmethacrylate in group 1, and with 7.0-mm expansive pedicle screws in group 2, and pullout testing was repeated to record maximum revision pullout strengths.Results: The mean pullout strengths recorded before and after revision were significantly different in both groups, being 2,162.9±718.5 N and 2,794.3±979.2 N in group 1 (p=0.041) and 2,605.0±487.6 N and 3,327.1±640.8 N in group 2 (p=0.012), respectively. However, the mean pullout strengths recorded before and after revision did not differ significantly between the two groups (p>0.05).Conclusion: Our results showed that expansive pedicle screws 1 mm larger in diameter provide similar pullout strengths to those of same-sized, polymethylmethacrylatereinforced screws in revision of pedicle screw fixation, suggesting that they can be preferred with the additional advantages of ease of application and avoiding risks for pedicle fracture and cement leakage., Amaç: Pedikül vidalarının revizyonlarında çeşitli yöntemler ve seçenekler kullanılmaktadır. Bunlardan ikisi vidaların çimentoyla güçlendirilmesi ve ucu genişleyebilen pedikül vidalarının (UGPV) kullanılmasıdır. Bu biyomekanik çalışmada, pedikül vida revizyonlarında kullanılan iki farklı tekniğin sıyırma güçleri karşılaştırıldı.Çalışma planı: Ortalama 15 aylık dört adet dananın lomber omurgalarından, her biri yedi adet omur içeren iki grup oluşturuldu. Omurların sağ pediküllerine 6 mm çaplı monoaksiyel pedikül vidaları uygulandı ve 10 mm/dk hızında aksiyel sıyırma testi yapıldı, yetmezlik değerleri kaydedildi. Grup 1’deki pediküllerin revizyonu 6 mm’lik pedikül vidası ve polimetilmetakrilat güçlendirmesi ile yapıldı. Grup 2’deki pediküllerin revizyonu ise 7 mm’lik, uç kısımları genişleyebilen pedikül vidaları ile yapıldı. Revizyon sonrasında örneklere aynı hızda sıyırma testi uygulandı ve değerler kaydedildi.Sonuçlar: Revizyon öncesi ve sonrası sıyırma güçleri her iki grupta da anlamlı farklılık gösterdi (grup 1’de sırasıyla 2162.9±718.5 N ve 2794.3±979.2 N, p=0.041; grup 2’de 2605.0±487.6 N ve 3327.1±640.8 N, p=0.012). İki grup arasında hem başlangıç sıyırma güçleri hem de revizyon sonrası sıyırma güçleri ortalamaları arasında anlamlı fark bulunmadı (p>0.05). Çıkarımlar: Pedikül vida revizyonlarında, 1 mm daha geniş UGPV’nin sıyırma gücünün, polimetilmetakrilatla güçlendirilmiş ve revizyon öncesiyle aynı çaptaki pedikül vidalarıyla benzer olduğu görüldü. Uç kısmı genişleyebilen pedikül vidaları, pedikül kırığı ve çimento sızma gibi riskleri taşımaması ve daha kolay uygulanabilmeleri nedeniyle revizyon cerrahisinde tercih edilebilir.

Objectives: To investigate whether an additional transpedicular screw fixation of the injured vertebra would increase the stability of posterior fixation. Methods: Ten fresh calf spine segments, each containing three motion segments, were obtained and anterior corpectomy was performed at the middle vertebra of each specimen. Posterior spinal instrumentation was performed in all specimens. In one group (n=5), screws were placed into the pedicle one level above and below the corpectomy level. In another group (n=5), additional transpedicular fixations were made at the corpectomy level. Stability of both groups was tested using compressive loads. The results were statistically evaluated using Mann-Whitney U-Wilcoxon rank sum W test. Results: The model showed not only that additional screw placement at the injury level did not contribute to the stability of the posterior stabilization of the vertebrae but also that screws applied to the corpectomied vertebra gave rise to additional injury to the pedicles.Conclusion: Due to small sample size and since only compressive forces were studied, further studies are required on flexion, extension, lateral bending, and torsional forces and the results should be supported by clinical studies., Amaç: Posterior stabilizasyona ek olarak vertebranın transpediküler vida ile tespitinin stabiliteye katkısı olup olmadığı araştırıldı. Çalışma planı: Üç tane hareketli segment içeren 10 adet taze lomber dana vertebrasında ortadaki segmente anterior korpektomi yapıldı. Tüm örneklerde, korpektomi yapılan seviyenin bir altındaki ve bir üstündeki vertebraların pediküllerine birer adet transpediküler vida gönderilerek rodlar aracılığı ile posterior stabilizasyon yapıldı. Bir grup örnekte (n=5) ise ek olarak korpektomi yapılan vertebralara da transpediküler vidalar uygulandı. Her iki gruba, aksiyel yükler uygulanarak örneklerin stabilitesi test edildi. Sonuçlar Mann-Whitney U-Wilcoxon rank sum W testi ile istatistiksel olarak değerlendirildi.Sonuçlar: Korpektomi yapılan seviyedeki ilave transpediküler vida fiksasyonunun stabiliteye ek bir katkısı olmadığı ve hatta test esnasında anterior kolon desteği olmadığı için bu vertebraların pediküllerinde vidaların manevale etkisi ile kolayca kırık oluştuğu gözlendi.Çıkarımlar: Çalışmamızda örnek sayısı az olduğundan ve tek bir yüklenme kuvvetine bakıldığından dolayı, ilaveten fleksiyon, ekstansiyon, laterale eğilme ve torsiyonel kuvvetlerin de değerlendirilerek sonuçların klinik çalışmalarla desteklenmesi yararlı olacaktır.

Objectives: We evaluated early results of treatment in patients with adolescent idiopathic scoliosis, who underwent anterior fusion with rigid single-rod third generation instrumentation and titanium surgical mesh implants.Methods: Seventeen patients (15 females, 2 males; mean age 14.9 years; range 11 to 20 years) with adolescent idiopathic scoliosis were included. Of the patient group, four had King type I, six had King type II, two had King type III, two had King type IV, and three patients had lumbar curves. Titanium mesh cages were used in all lumbar procedures, and at the cranial and caudal ends of the instrumented area in thoracic cases. All patients were immobilized in a TLSO for three to six months postoperatively. Preoperative, postoperative and follow-up ortho-radiographs were evaluated. The mean follow-up was 28 months (range 18 to 41 months).Results: The mean pre- and postoperative primary coronal Cobb angles were 51° and 8.6°, respectively. The mean correction was 83.9%. Sagittal balance was also restored with mean angles of 27.5° and 37.6° for thoracic kyphosis and lumbar lordosis, respectively. Spontaneous secondary curve decompensation did not occur. Compared with posterior surgery, the mean number of lumbar levels saved was calculated as 0.93. Postoperative thoracolumbar junctional kyphosis did not develop. Loss of correction, nonunion, and implant failure were not encountered; however, one thoracic case required revision with posterior surgery for proximal screw pull-out.Conclusion: Our early results indicate that anterior correction using third generation single solid rod instrumentation and titanium mesh cages offers a good alternative to posterior instrumentation., Amaç: Üçüncü kuşak anterior vida;tek çubuk sistemleri ve intervertebral titanyum mesh kullanılarak tedavi edilen adölesan idiopatik skolyozlu olgularda erken dönem tedavi sonuçları değerlendirildi.Çalışma planı: Adölesan idiopatik skolyozlu 17 hasta (15 kadın, 2 erkek; ort. Yaş 14.9:dağılım 11-20) değerlendirildi. Eğrilikler dört olguda King tip I, altı olguda tip II, iki olguda tip III, iki olguda tip IV ve üç olguda lomber olarak sınıflandırıldı. Lomber olgularda tüm seviyelerde, torakal olgularda ise enstrümantasyonun kranial ve kaudal sınırlarında intervertebral titanyum mesh$ler kullanıldı. Tüm olgular ameliyat sonrası 3-6 ay süreyle torakolumbosakral ortez içinde immobilize edildi. Hastaların ameliyat öncesi, ameliyat sonrası ve takiplerinde iki yönlü orthoröntgenografileri değerlendirildi. Ortalama takip süresi 28 ay (dağılım 18-41 ay) idi.Sonuçlar: Koronal eğrilik derecesi ortalamaları ameliyat öncesinde 51, ameliyat sonrasında 8.6 bulundu. Koreksiyon oranı ortalaması %83.9 idi. Ameliyat sonrası sagital açı değerleri ortalaması torakal kifoz için 27.5, lomberlordoz için 37.6 bulundu. Sekonder eğriliklerin hiçbirinde dekompensasyon gelişmedi. Posterior enstrümantasyon ile karşılaştırıldığında ortalama 0.93 seviye füzyondan tasarruf edildi. Torakolomber geçiş bölgesi kifozu saptanmadı. Bir torasik olguda vida sıyırması nedeniyle, erken dönemde posterior enstrümentasyon ile revizyon uygulandı. Takiplerde psödoartroz, implant yetersizliği ve koreksiyon kaybı gibi problemlerle karşılaşılmadı,Çıkarımlar: Sonuçlarımız üçüncü kuşak anterior tek çubuk enstrümentasyon ve intervertebral titanyum mesh'lerin adölesan idiopatik skolyozun cerrahi tedavisinde posterior enstrümentasyona iyi bir alternatif olduğunu gösterdi.

Objectives: We studied the pull-out strengths of two types of pedicular screws, designed by the authors, in calf lumbar vertebrae.Methods: In this experimental study we evaluated the pullout strengths of three screw types in calf lumbar vertebrae. Expandable distal tipped screws used in groups A and B were designed by the authors. These screws were made up of two parts, with an outer diameter of 6.5 mm. The distal tips of the screws are forced to expand outwards when a pin inserted (i) from the distal tip is pulled from the back of the screw (group A), and (ii) from the back of the screw is advanced toward the tip (Group B). Group C included 6 mm Cotrel-Dubousset (CD) screws. Pull-out tests were performed in 22 vertebrae using screws in groups A (n=7), B (n=7), and C (n=8).Results: Screws in group B were found to exhibit the highest average pull-out strength (mean 1238.57 Newton), followed by the screws in Group A (mean 1124.28 Newton), whereas the CD screws in Group C had the lowest average pull-out strength (mean 978.75 Newton). Paired comparisons between the groups B and C, and the groups A and C showed statistically significant differences with regard to pull-out strengths (p, Amaç: Tasarımını yaptığımız pediküler vida tiplerinin sıyırma kuvvetlerini dana vertebralarında değerlendirdik.Çalışma planı: Bu deneysel biyomekanik çalışmada üç tip vidanın sıyırma kuvvetlerini dana vertebralarında değerlendirdik. A ve B grubunu oluşturan, uç kısımları açılabilir (dübel tipi) vidaların tasarımı tarafımızca oluşturuldu. 6.5 mm dış çapı olan ve iki parçadan oluşan bu vidalardan A grubunda uç kısımdan sokulan milin geriye çekilmesiyle, B grubunda arka kısımdan sokulan milin ilerletilmesiyle uç kısımlar kanat şeklinde açılmaktadır. C grubunda Cotrel-Dubousset (CD) 6 mm’lik vidaları kullanıldı. Toplam 22 vertebrada A ve B grubunda yedişer, C grubunda sekiz vida kullanarak sıyırma testi uyguladık.Sonuçlar: Sıyırma kuvvetleri açısından, B grubunu oluşturan vidaların en yüksek değerlere sahip oldukları (ort. 1238.57 Newton), bunu A grubunu oluşturan vidaların (ort. 1124.28 Newton) izlediği görüldü. C grubunu oluşturan CD tipi vidalar en düşük sıyırma kuvvetine sahipti (ort. 978.75 Newton). B ve C gruplarıyla A ve C grupları arasındaki sıyırma kuvvetleri farkları istatistiksel olarak anlamlı bulundu (p

Objectives: Although spinal fusion is one of the most commonly used procedures in spinal surgery its properties are not fully known. The role of decortication is still not clear. In this animal model, we investigated the effect of decortication on spinal fusion.Methods: The study included 30 male guinea pigs (Cavia porcellus). Spine exposure was obtained through the right subperiosteal dissection between L2 and L6 in all animals, whereas the left sides were used as controls. The animals were assigned to three groups including decortication and autografting (group 1), decortication, instrumentation, and autografting (group 2), and instrumentation and autografting without decortication (group 3). All animals were sacrificed in the sixth postoperative week. The fusion mass was assessed by means of macroscopic evaluation, manual stress test, radiologic examination, and microscopic evaluation.Results: Based on segmentary evaluations, fusion was obtained in 80%, 95%, and 92.5% in groups 1, 2, and 3, respectively. The results were found statistically significant (Kruskal-Wallis nonparametric ANOVA test, p, Amaç: Spinal füzyon, spinal cerrahinin en sık uygulanan bir işlemi olmasina rağmen özellikleri halen tam olarak bilinmemektedir. Dekortikasyonun bu işlemdeki rolü ise tartışmalıdır. Bu çalışmada dekortikasyonun spinal füzyondaki etkisi araştırıldı.Çalışma planı: Otuz erkek kobay (guinea pig, Cavia porcellus) kullanılarak in vivo deneysel hayvan modeli oluşturuldu. Tüm hayvanlarda L2-L6 arası omurga, sağ taraftan subperiosteal diseksiyon ile ortaya çıkarıldı. Omurganın sol tarafı kontrol grubu olarak kullanıldı. Hayvanlar uygulanan işlemlere göre üç gruba ayrıldı: Dekortikasyon+otogreft (grup 1), dekortikasyon+enstrümantasyon+otogreft (grup 2) ve dekortikasyonyapılmadan enstrümantasyon+otogreft (grup 3). Cerrahiden sonra altıncı haftada hayvanlar öldürülerek oluşan füzyon kütlesi makroskobik olarak, elle stres testi ile, radyolojik olarak ve mikroskobik olarak değerlendirildi.Sonuçlar: Segmentlere göre değerlendirmede grup l'de %80, grup 2'de %95, grup 3'te %92.5 füzyon elde edildi. Bu değerler istatistiksel olarak Kruskal-Wallis nonparametric ANOVA testinde anlamlı bulundu (p

This study aims to evaluate the influence of bone harvesting on postoperative pain and fusion rates. Group 1 patients received iliac crest bone graft (ICBG) either alone or augmented with local bone. Group 2 received only local bone. No statistical significance was found in radiological union or in the Oswestry Disability Index scores. Visual Analogue Scale scores showed less pain in group 2. Logistic regression showed no correlation between residual pain and occurrence of fusion. Harvesting ICBG did not appear to increase fusion rates and no relation was found between radiological non-union and pain.

OBJETIVO: Procuramos avaliar a eficácia terapêutica de estabilizadores interespinosos na doença degenerativa lombar, e a evolução do índice de depressão e somatização de sintomas preexistentes nesses pacientes. MÉTODOS: Estudamos 20 pacientes com estenose de canal lombar. Considerados diversos critérios de inclusão, os pacientes concordaram em participar do estudo assinando o consentimento livre e esclarecido. Na avaliação clínica e psicossomática utilizamos: Escore Euroqol (EQ-5D); escala visual analógica (EVA) lombar e dos membros inferiores; Oswestry Disability Index versão 2.0 e Modified Somatic Perception Questionnaire (MSPQ) e Zung Self-Rating Depression Scale (ZDS). A análise estatística foi realizada com os testes de Friedman e Wilcoxon, sendo o nível de significância 0,05. RESULTADOS: Existiu uma melhoria em EQ-5D (p

BACKGROUND AND PURPOSE: Several studies have investigated outcomes after disc surgery. However, the occurrence of kinesiophobia has not been investigated previously in patients after disc herniation surgery. In this cross-sectional study, we investigated kinesiophobia in patients who had been treated surgically for lumbar disc herniation, and we related the results to established outcome measures. PATIENTS AND METHODS: 10-34 months after surgery, questionnaires were sent to 97 patients who had undergone standardized open discectomy. Outcome measures included Tampa scale for kinesiophobia (TSK); Oswestry disability index (ODI); European quality of life in 5 dimensions (EQ-5D); visual analog scale (VAS) for leg and back pain, work disability, and patient satisfaction; Zung self-rating depression scale (ZDS); pain catastrophizing scale (PCS); and a self-efficacy scale (SES). RESULTS: 36 of 80 patients reported having kinesiophobia. There were statistically significant differences in ODI, EQ-5D, VAS leg and back pain, ZDS, PCS, and SES between patients with and without kinesiophobia. INTERPRETATION: Half of the patients suffered from kinesiophobia 10-34 months after surgery for disc herniation. These patients were more disabled, had more pain, more catastrophizing thoughts, more symptoms of depression, lower self-efficacy, and poorer health-related quality of life than patients without kinesiophobia.

OBJECT: The objective of this study was to examine the efficacy and safety of Healos graft carrier with bone marrow aspirate and local autograft compared with the results of allograft in patients with lumbar degenerative scoliosis undergoing posterolateral fusion. METHODS: Twenty-eight patients with degenerative scoliosis underwent posterolateral instrumented fusion and decompression. Patients were grouped according to the graft used. Group A consisted of 12 cases in which the authors used a Healos graft carrier, bone marrow aspirate, and local autograft, and Group B consisted of 16 cases in which the authors used cancellous allograft and local autograft. Patients were followed for a minimum of 2 years postoperatively in terms of pain (visual analog scale), function (Oswestry Disability Index), curve magnitude (Cobb angle), and fusion status (plain and dynamic radiographs). The 2 groups did not differ statistically significantly (p > 0.05) in age, sex, smoking habits, magnitude of preoperative visual analog scale score, Oswestry Disability Index score, Cobb angle, or number of levels requiring decompression and fusion. RESULTS: The groups had similar (p > 0.05) results in terms of pain, function, curve progression, and fusion rates at the 2-year follow-up examination. Radiographic fusion was achieved in all but 2 cases, 1 in each group, in which the patients were asymptomatic. Patients in the allograft group (Group B) showed evidence of fusion earlier than in the Healos group (p < 0.05). No toxicity from Healos graft was recorded. CONCLUSIONS: The combination of Healos hydroxyapatite sponge and bone marrow aspirate plus local allograft had significantly slower fusion rates but equal clinical outcomes compared with cancellous allograft plus local autograft when used for posterolateral fusion in patients with degenerative lumbar scoliosis. J Neurosurg Spine

The aim of this study was to compare our experience with minimally invasive transforaminal lumbar interbody fusion (MITLIF) and open midline transforaminal lumbar interbody fusion (TLIF). A total of 36 patients suffering from isthmic spondylolisthesis or degenerative disc disease were operated with either a MITLIF (n = 18) or an open TLIF technique (n = 18) with an average follow-up of 22 and 24 months, respectively. Clinical outcome was assessed using the visual analogue scale (VAS) and the Oswestry disability index (ODI). There was no difference in length of surgery between the two groups. The MITLIF group resulted in a significant reduction of blood loss and had a shorter length of hospital stay. No difference was observed in postoperative pain, initial analgesia consumption, VAS or ODI between the groups. Three pseudarthroses were observed in the MITLIF group although this was not statistically significant. A steeper learning effect was observed for the MITLIF group.