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This study evaluates the impact of L4-L5 minimally invasive surgery (MIS)– transforaminal lumbar interbody fusion (TLIF) on adjacent-level parameters. This is a retrospective study performed on consecutive patients between January 2015 and December 2019. The index- and adjacent-level segmental lordosis (SL) and disc angle (DA) were measured. Patient-reported outcomes (PROs) were collected preoperatively and at 3–24 months postoperatively. Factors influencing changes in adjacent-level parameters and the occurrence of adjacent segment degeneration (ASDeg) were assessed. A total of 117 adult patients, averaging 65.5 years of age and slight preponderance of female (56.4%), were analyzed. L4-L5 SL decreased at 2 years (P < 0.05), but L4-L5 DA significantly increased at all timepoints (P < 0.05). While L3-L4 SL and DA significantly decreased at all timepoints (P < 0.05), L5-S1 SL decreased at 3 and 12 months (P < 0.05) and L5-S1 DA only significantly decreased at 2 years (P < 0.05). All PROs improved significantly (P < 0.0001). The ASDeg rate was 19.7% at 2.2 years. Cephalad and caudal ASDeg rates were 12.0% and 10.3%, respectively. Eight patients (6.8%) required adjacent-level reoperations, mainly at L3-L4 (6 cases). The use of expandable cage significantly reduced the odds of caudal ASDeg (OR 0.15, P = 0.037), but had no significant effect on cephalad ASDeg. L4-L5 MIS-TLIF had a more consistent effect on L3-L4 than L5-S1. Although adjacent-level SL and DA decreased over time, their association with ASDeg appears limited, suggesting a multifactorial etiology. L4-L5 MIS-TLIF provides demonstrable clinical benefits with lasting PRO improvements and low adjacent-level reoperations. [ABSTRACT FROM AUTHOR]

Objective To perform a systematic literature review on revision surgeries at the index level after cervical disc arthroplasty (CDA) failure. Methods A systematic literature review was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Prospective studies on patients who required a secondary surgery after CDA failure were included for analysis. The minimum follow-up for these studies was 5 years. Results Out of 864 studies in the original search group, a total of 20 studies were included. From a total of 4,087 patients, 161 patients required a reoperation at the index level. A total of 170 surgeries were performed, as some patients required multiple surgeries. The most common secondary procedures were anterior cervical discectomy and fusion (ACDF) (68%, N = 61) and posterior cervical fusion (15.5%, N = 14), followed by other reoperation (13.3%, N = 12). The associated outcomes for those who required a revision surgery were rarely mentioned in the included literature. Conclusion The long-term revision rate at the index level of failed CDA surgery was 3.9%, with a minimum 5-year follow-up. ACDF was the most commonly performed procedure to salvage a failed CDA. Some patients who required a new surgery after CDA failure may require a more extensive salvage procedure and even subsequent surgeries.

Objective: To perform a systematic literature review on revision surgeries at the index level after cervical disc arthroplasty (CDA) failure. Methods: A systematic literature review was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Prospective studies on patients who required a secondary surgery after CDA failure were included for analysis. The minimum follow-up for these studies was 5 years. Results: Out of 864 studies in the original search group, a total of 20 studies were included. From a total of 4,087 patients, 161 patients required a reoperation at the index level. A total of 170 surgeries were performed, as some patients required multiple surgeries. The most common secondary procedures were anterior cervical discectomy and fusion (ACDF) (68%, N = 61) and posterior cervical fusion (15.5%, N= 14), followed by other reoperation (13.3%, N = 12). The associated outcomes for those who required a revision surgery were rarely mentioned in the included literature. Conclusion: The long-term revision rate at the index level of failed CDA surgery was 3.9%, with a minimum 5-year follow-up. ACDF was the most commonly performed procedure to salvage a failed CDA. Some patients who required a new surgery after CDA failure may require a more extensive salvage procedure and even subsequent surgeries. [ABSTRACT FROM AUTHOR]

Abstract Background Thoracic and lumbar fractures represent nearly 90% of traumatic spine injuries. Thoracolumbar region is susceptible to injury because of its location between the stiff kyphotic thoracic spine and the mobile lordotic lumbar region. To compare between short-segment fixation with screws into index level and long-segment fixation in maintaining angle of correction and pain. Methods A prospective study included 91 patients, who had single-level thoracolumbar fracture with Cobb’s angle ≤ 25° and underwent posterior fixation. Forty-four patients underwent short-segment fixation with screws into the index level, and 47 patients underwent long-segment fixation with skipped index level. The angle of correction, pain, and neurological state were regularly assessed. Results Forty-four patients (48.35%) had short segment and 47 (51.65%) had long-segment fixation. In the short segment group, the pre-operative mean Cobb’s angle was 19.34° ± 3.63° and the angle of correction was 8.14° ± 1.9° after 1 year, while in the long segment group, the pre-operative mean Cobb’s angle was 19.08° ± 4.0° and the angle of correction was 8.62° ± 2.59°. Regarding pain, in the short segment group, the pre-operative visual analogue scale (VAS) was 5.59 ± 2.09 that was reduced to 1.39 ± 0.58 at the 1 year follow-up, while the long segment group VAS was 5.4 ± 2.01 pre-operatively that was reduced to 1.47 ± 0.58. Conclusions Short-segment fixation can maintain the angle of correction as long-segment fixation for single level thoracolumbar traumatic fracture with lower complication and faster pain relief. Trial registration Clinicaltrials.gov/NCT03272243. Registered: 1 September 2017.

Vertebral body replacement is a common surgical procedure for treatment of disorders associated with spinal instability. Therefore, pedicle screws are usually inserted in adjacent vertebrae for stabilization of the posterior column, however, there is lack of evidence whether implantation of index-level pedicle screws is beneficial or not. This biomechanical study aims to investigate the effect of pedicle screw instrumentation on axial stability following vertebral body replacement. Unstable fracture at L3 level was simulated in lumbar spines from six human cadaveric specimens. Then instrumentation was performed one level above / one level below index level in three specimens and further, three specimens were instrumented at index-level (L3) additionaly. Then we used a testing protocol for biomechanical evaluation of axial loading on human cadaveric lumbar spines until cage subsidence occurred. Our results show that index-level instrumented spines endured significantly higher load until cage subsidence occurred compared to non-index-level instrumented specimens (p = 0.05). Our results demonstrate pedicle screw instrumentation at index-level vertebra should be considered when possbile as it may have a protective effect against cage subsidence in patients undergoing vertebral body replacement surgery. • Biomechanical testing of axial loading after vertebral body replacement. • Index-level instrumented spines endured significantly higher load than without. • Index-level pedicle screw instrumentation significantly increases axial loading capability. [ABSTRACT FROM AUTHOR]

Objective The purpose of this review was to investigate whether cervical total disc arthroplasty (CTDA) preserves motion of the treated level and what its effect is on adjacent segments. Methods Relevant published reports were collected from PubMed, Medline and Cochrane library. The original studies were considered eligible only if the range of motion ( ROM) of the index or adjacent level had been investigated. A meta-analysis was then performed on the collected data. Statistical heterogeneity across the various trials was tested using Cochran's Q statistic and I2; in the case of heterogeneity, a random effect model was used. Results The weighted mean differences ( WMDs) of the index level were 0.34 (95% confidence interval [ CI], −0.53∼1.21, P = 0.440) and 0.23 (95% CI, −1.92∼2.38, P = 0.834) in all included studies and randomized control trials ( RCTs), respectively. The WMDs of the cranial adjacent levels, caudal adjacent levels and whole cervical spines were 1.01 (95% CI, 0.55∼1.47, P = 0.000), 1.10 (95% CI, 0.61∼1.59, P = 0.000) and 3.40 (95% CI, −6.02∼12.82, P = 0.479), respectively. Conclusion These findings suggest that the protective effect against adjacent segment degeneration provided by cervical arthroplasty might not be as good as has been believed. Long-term supporting evidence is still needed. [ABSTRACT FROM AUTHOR]

Background: The literature reports that index level (IL) revision spine surgery (RSS) and adjacent level (AL) RSS are diminished in lumbar TDR compared with fusion procedures. There is a paucity of PROMs reported after RSS., Objective: To present the incidence of RSS at the IL and AL following single-level lumbar total disc replacement (TDR) and to document patient-related outcome measures (PROMs) associated with RSS., Methods: PROMs and timelines were analyzed for 32 RSS patients from a prospective cohort study of 401 patients treated with TDR for single-level degenerative disc disease. The data collected prospectively are analyzed from baseline (prior to index surgery) to latest follow-up following RSS. PROMs, including visual analog scales for back and leg, Oswestry Disability Index, and Roland-Morris Disability Questionnaire, were collected preoperatively; postoperatively at 3, 6, and 12 months; and annually thereafter until RSS. The time to RSS was recorded, and PROMs for RSS (IL, AL, or both) were documented, analyzed, and compared., Results: The median time to RSS in the IL cohort was 35 months (interquartile range [IQR] = 9-51 months). The median time to RSS cohort was 70 months (IQR = 41.3-105.3 months). Timepoints facilitate PROM discussion for RSS. Patients in both groups achieved thresholds for the minimum clinically important difference for pain and disability scores. The small sample size in each group contributed to the variability demonstrated by the 95% CIs, thereby cautioning definitive conclusions., Conclusions: This study reveals that statistically significant and modest clinical improvements in PROMs can be achieved in RSS for lumbar TDR at IL and AL. The surgical approach and technique are reflective of the pathology and suggest that anterior RSS for AL degeneration and posterior RSS for IL pathology yield similar results., Clinical Relevance: Statistical and clinical improvements can be achieved in IL-RSS and AL-RSS following single level TDR. It is essential for clinicians to understand and verify the underlying IL and/or AL pathology to select an appropriate management strategy and to facilitate balanced informed discussions with patients., Competing Interests: Declaration of Conflicting Interests: Matthew Scott-Young previously received royalties and had a consulting agreement with DePuy Spine. The remaining authors report no disclosures., (This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2022 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.)

Studies on the role of uncinate process have been limited to responses of the intact spine and patient's outcomes, and procedures to perform the excision. The aim of this study was to determine the role of uncinate process on the biomechanical response at the index and adjacent levels in three artificial discs used in cervical disc arthroplasty. A validated finite element model of cervical spine was used. Flexion, extension, and lateral moments and follower load were applied to Bryan, Mobi-C, and Prestige LP artificial discs at C5-C6 level with and without uncinate process. Ranges of motion at index level and adjacent caudal and cranial segments, intradiscal pressures at adjacent segments, and facet loads at index level and adjacent segments were obtained. Data were normalized with respect to the preservation of uncinate process. Uncinate process removal increased motions up to 27% at index and decreased up to 10% at adjacent levels, decreased disc pressures up to 14% at adjacent segments, decreased facet loads at adjacent segments up to 14%, while at index level, change in loads depended on mode and arthroplasty, with Mobi-C responding with up to 51% increase and Bryan disc up to 11% decrease, while Prestige LP increased loads by 17% in extension and decreased by 9%% in lateral bending. As surgical selection is based on morphology and surgeon's experience, the present computational findings provide quantitative information for an optimal choice of the device and procedure, while further studies (in vitro/clinical) would be required. • Uncinate process excision leads to increased motion at index level in cervical disc arthroplasty. • Adjacent segment intradiscal pressures increase without the process and with arthroplasty. • Facet loads reduce more in extension than lateral bending without process with arthroplasty. • Facet loads are greater in cranial than caudal segments without process with arthroplasty. [ABSTRACT FROM AUTHOR]

Background: Thoracic and lumbar fractures represent nearly 90% of traumatic spine injuries. Thoracolumbar region is susceptible to injury because of its location between the stiff kyphotic thoracic spine and the mobile lordotic lumbar region. To compare between short-segment fixation with screws into index level and long-segment fixation in maintaining angle of correction and pain. Methods: A prospective study included 91 patients, who had single-level thoracolumbar fracture with Cobb's angle ≤ 25° and underwent posterior fixation. Forty-four patients underwent short-segment fixation with screws into the index level, and 47 patients underwent long-segment fixation with skipped index level. The angle of correction, pain, and neurological state were regularly assessed. Results: Forty-four patients (48.35%) had short segment and 47 (51.65%) had long-segment fixation. In the short segment group, the pre-operative mean Cobb's angle was 19.34° ± 3.63° and the angle of correction was 8.14° ± 1.9° after 1 year, while in the long segment group, the pre-operative mean Cobb's angle was 19.08° ± 4.0° and the angle of correction was 8.62° ± 2.59°. Regarding pain, in the short segment group, the pre-operative visual analogue scale (VAS) was 5.59 ± 2.09 that was reduced to 1.39 ± 0.58 at the 1 year follow-up, while the long segment group VAS was 5.4 ± 2.01 pre-operatively that was reduced to 1.47 ± 0.58. Conclusions: Short-segment fixation can maintain the angle of correction as long-segment fixation for single level thoracolumbar traumatic fracture with lower complication and faster pain relief. Trial registration: Clinicaltrials.gov/NCT03272243. Registered: 1 September 2017. [ABSTRACT FROM AUTHOR]

Background: Anterior interbody fusion has previously been demonstrated to increase neuroforaminal height in a cadaveric model using cages. No prior study has prospectively assessed the relative change in magnetic resonance imaging (MRI) demonstrated neuroforaminal dimensions at the index and supradjacent levels, after anterior interbody fusion with a corticocancellous allograft in a series of patients without posterior decompression. The objective of this study was to determine how much foraminal dimension can be increased with indirect foraminal decompression alone via anterior interbody fusion, and to determine the effect of anterior lumbar interbody fusion on the dimensions of the supradjacent neuroforamina., Methods: A prospective study comparing pre- and postoperative neuroforaminal dimensions on MRI scan among 26 consecutive patients undergoing anterior lumbar interbody fusion without posterior decompression was performed. We studies 26 consecutive patients (50 index levels) that had undergone anterior interbody fusion followed by posterior pedicle screw fixation without distraction or foraminotomy. We used preoperative and postoperative MRI imaging to assess the foraminal dimensions at each operated level on which the lumbar spine had been operated. The relative indirect foraminal decompression achieved was calculated. The foraminal dimension of the 26 supradjacent untreated levels was measured pre- and postoperatively to serve as a control and to determine any effects after anterior interbody fusion., Results: In this study, 8 patients underwent 1 level fusion (L5-S1), 12 patients had 2 levels (L4-S1) and 6 patients had 3 levels (L3-S1). The average increase in foraminal dimension was 43.3% (p < 0.05)-19.2% for L3-4, 57.1% for L4-5, and 40.1% for L5-S1. Mean pre- and postoperative supradjacent neuroforaminal dimension measurements were 125.84 mm(2) and 124.89 mm(2), respectively. No significant difference was noted (p > 0.05)., Conclusions: Anterior interbody fusion with a coriticocancellous allograft can significantly increase neuroforaminal dimension even in the absence of formal posterior distraction or foraminotomy; anterior interbody fusion with a coriticocancellous allograft has little effect on supradjacent neuroforaminal dimensions.