Dezsö Jeszenszky

Comparison of anterior and posterior instrumentation for correction of adolescent thoracic idiopathic scoliosis

STUDY DESIGN This was a prospective study of two cohort groups of patients (one group receiving anterior instrumentation and the other posterior instrumentation) receiving treatment for thoracic idiopathic scoliosis. OBJECTIVE To present the 2-year postoperative results of a prospective multicenter study comparing the use of anterior instrumentation with that of posterior multisegmented hook instrumentation for the correction of adolescent thoracic idiopathic scoliosis. SUMMARY OF BACKGROUND DATA Despite reports of satisfactory results, problems have been reported with posterior systems, including worsening of the lumbar curve after surgery and failure to correct hypokyphosis. Theoretically, the advantages of anterior instrumentation include prevention of lumbar curve decompensation by shortening the convexity of the thoracic curve. In addition, by removing the disc, better correction of thoracic hypokyphosis could be obtained. METHODS Seventy-eight patients who underwent an anterior spinal fusion using flexible threaded rods and nuts (Harms-MOSS instrumentation, De Puy-Motech-Acromed, Cleveland, OH) were analyzed and compared with 100 patients who underwent posterior spinal fusion with multisegmented hook systems. Parameters of comparison included coronal and sagittal correction, balance, distal lumbar fusion levels, and complication. All patients had idiopathic thoracic curves of King Types II to V. The average age at surgery was 14 years in each group, the average preoperative curve 57 degrees, and the minimum duration of follow-up for all patients 24 months. All data were collected prospectively and analyzed via Epl into statistical analysis (Centers of Disease Control, Atlanta, GA). RESULTS Average coronal correction of the main thoracic curve was 58% in the anterior group and 59% in the posterior group (P = 0.92). Analysis of sagittal contour showed that the posterior systems failed to correct a preoperative hypokyphosis (sagittal T5 to T12 less than 20 degrees) in 60% of cases, whereas 81% were normal postoperatively in the anterior group. However, hyperkyphosis (sagittal T5 to T12 greater than 40 degrees) occurred after surgery in 40% of the anterior group when the preoperative kyphosis was greater than 20 degrees. Postoperative coronal balance was equal in both groups. An average of 2.5 (range, 0-6) distal fusion levels were saved using the anterior spinal instrumentation according to the criteria used for determining posterior fusion levels in this study. Selective fusion of the thoracic curve (distal fusion level T11, T12, L1) was performed in 76 of 78 patients (97%) in the anterior group as compared with only 18 of 100 (18%) in the posterior group. Surgically confirmed pseudarthrosis occurred in 4 of 78 patients (5%) in the anterior group and in 1 of 100 patients (1%) in the posterior group (P = 0.10). Loss of correction greater than 10 degrees occurred in 18 of 78 patients (23%) in the anterior group and in 12 of 100 patients (12%) in the posterior group (P = 0.01). Implant breakage occurred in 24 patients (31%) of the anterior group and in only 1 patient (1%) of the posterior group. CONCLUSIONS 1) Coronal correction and balance were equal in both the anterior and posterior groups, even though the anterior group had the majority of curves (97%) fused short or to L1, whereas only 18% were fused short or to L1 in the posterior group. 2) In the anterior group there was a better correction of sagittal profile in those with a preoperative hypokyphosis less than 20 degrees. However, hyperkyphosis (with a mean of 54 degrees) occurred in 40% of those in the anterior group with a preoperative kyphosis of more than 20 degrees. 3) An average of 2.5 lumbar levels can be saved with anterior fusion and instrumentation according to the criteria used for choosing posterior fusion levels in this study. 4) Using the 3.2-mm flexible rod in this study, loss of correction, pseudarthrosis, and rod breakage were unacceptably highe

Die posteriore, lumbale, interkorporelle Fusion in unilateraler transforaminaler Technik

ZusammenfassungOperationszielBeseitigung von schmerzhaften Wirbelsäuleninstabilitäten und Dekompression nervaler Strukturen durch interkorporelle Fusion. Wiederherstellung der Form und Wirbelsäulenfunktion.IndikationenSegmentale Instabilität(en) bei chronischen, therapieresistenten Lumboischialgien infolge von Diskushernie und-protrusion, Osteochondrose, Spondylolisthese oder Spinalstenose.KontraindikationenKyphotische und fixierte Fehlstellungen der Lendenwirbelsäule, anatomische Anomalien oder Vernarbungen im oder um das Foramen intervertebrale, Kreuzschmerzen ohne neurologische Symptome, ungünstige psychosoziale Bedingungen.OperationstechnikEinseitige Öffnung des Foramen intervertebrale und Ausräumung der Bandscheibe nach Teilresektion von Gelenkanteilen des kranialen und kaudalen Wirbelkörpers. Bilaterale Distraktion zur Erweiterung des Bandscheibenfaches mit einem Schrauben-Stab-System. Implantation von autogenem Knochen und zwei metallischen Abstützkörpern. Wiederherstellung der Segmentstabilität durch Kompression der dorsalen Instrumentation gegen die vorderen Abstützkörper.ErgebnisseVon Oktober 1993 bis August 1996 wurden 191 Patienten operiert, 89 Männer und 102 Frauen im Durchschnittsalter von 53 Jahren (zwölf bis 82 Jahre). Diagnosen siehe Tabelle 1, fusionierte Segmente siehe Tabelle 2, intra- und postoperative Komplikationen siehe Tabelle 3.Postoperative Kontrollen nach drei, sechs und zwölf, zum Teil nach 24 Monaten. Schmerzstatus nach Denis siehe Tabelle 5. Die besten Resultate wurden bei degenerativer Spondylolisthese und isthmischer Defektspondylolisthese erzielt. Beim Postnukleotomiesyndrom “nur” in 60% gute bis befriedigende Resultate.

The Influence of Preoperative Back Pain on the Outcome of Lumbar Decompression Surgery

Study Design. Prospective study with 12-month follow-up. Objective. To examine how the relative severity of low back pain (LBP) to leg/buttock pain (LP) influences the outcome of decompression surgery for spinal stenosis. Summary of Background Data. Decompression surgery is a common treatment for lumbar spinal canal stenosis, with generally good outcome. However, concomitant LBP at presentation can make it difficult to decide whether decompression alone will result in a good overall outcome. Methods. The Spine Society of Europe Spine Tango system was used to acquire the data from 221 patients. Inclusion criteria were lumbar degenerative spinal stenosis, first-time surgery, maximum 3 affected levels, and decompression as the only procedure. Before and 12 months after surgery, patients completed the multidimensional Core Outcome Measures Index (COMI; includes 0–10 LP and LBP scales); at 12 months, global outcome was rated on a Likert-scale and dichotomized into “good” and “poor” groups. Results. There was a low but significant positive correlation between baseline LP-minus-LBP scores and both improvement in the multidimensional COMI score after 12 months (r = 0.21, P = 0.003) and the score on the 12-month global outcome scale (r = 0.19, P = 0.007). In the good outcome group, mean baseline LP was 2.3 (±3.7) points higher than LBP; in the poor group, the corresponding value was 0.8 (±3.4) (P = 0.01 between groups). In multivariate regression analyses (controlling for age, gender, comorbidity), baseline LBP intensity was the most significant predictor of the 12-month COMI score, and preoperative LP-minus-LBP score of the global outcome (each P < 0.05). Conclusion. Overall, greater back pain relative to LP at baseline was associated with a significantly worse outcome after decompression. This finding seems intuitive, but has rarely been quantified in the many predictor studies conducted to date. Consideration of relative LBP and LP scores may assist in clinical decision-making and in establishing realistic patient expectations.

Multimodal intraoperative monitoring during surgery of spinal deformities in 217 patients

A prospective study was performed on 217 patients who received MIOM during corrective surgery of spinal deformities between March 2000 and December 2005. Aim is to determine the sensitivity and specificity of MIOM techniques used to monitor spinal cord and nerve root function during corrective spine surgery. MIOM is becoming an increasingly used method of monitoring function during corrective spine surgery. The combination of monitoring of ascending and descending pathways may provide more sensitive and specific results giving immediate feedback information regarding any neurological deficits during the operation. Intraoperative somatosensory spinal and cerebral evoked potentials combined with continuous EMG and motor evoked potentials of the spinal cord and muscles were evaluated and compared with postoperative clinical neurological changes. A total of 217 consecutive patients with spinal deformities of different aetiologies were monitored by means of MIOM during the surgical procedure. Out of which 201 patients presented true negative findings while one patient presented false negative and three patients presented false positive findings. Twelve patients presented true positive findings where neurological deficit after the operation was predicted. All neurological deficits in those 12 patients recovered completely. The sensitivity of MIOM applied during surgery of spinal deformities has been calculated of 92.3% and the specificity 98.5%. Based upon the results of this study MIOM is an effective method of monitoring the spinal cord and nerve root function during corrective surgery of spinal deformities and consequently improves postoperative results. The Wake-up test for surgical procedure of spinal deformities became obsolete in our institution.

The validity of multimodal intraoperative monitoring (MIOM) in surgery of 109 spine and spinal cord tumors

In a prospective study of 109 patients with tumor of the spine MIOM was performed during the surgical procedure between March 2000 and December 2005. To determine the sensitivity and specificity of MIOM techniques used to monitor spinal cord and nerve root function during surgical procedure of spinal tumors. MIOM become an integrated procedure during surgical approach to intramedullar and extramedullar spine tumors. The combination of monitoring ascending and descending pathways may provide more sensitive and specific results than SEP alone giving immediate feedback information regarding any neurological deficit during the operation. Intraoperative sensory spinal and cerebral evoked potential combined with EMG recordings and motor evoked potential of the spinal cord and muscles were evaluated and compared with postoperative clinical neurological changes. One hundred and nine consecutive patients with spinal tumors of different aetiologies were monitored by the means of MIOM during the entire surgical procedure. Eighty-two patients presented true negative findings while two patients monitored false negative, one false positive and 24 patients true positive findings where neurological deficits after the operation were present. All patients with neurological deficit recovered completely or to pre-existing neurological situation. The sensitivity of MIOM applied during surgery of spinal tumors has been calculated of 92% and specificity 99%. Based upon the results of the study MIOM is an effective method of monitoring the spinal cord and nerve root function during surgical approach of spinal tumors and consequently can reduce or prevent the occurrence of postoperative neurological deficit.

Multimodal intraoperative monitoring (MIOM) during cervical spine surgical procedures in 246 patients

A prospective study of 246 patients who received multimodal intraoperative monitoring during cervical spine surgery between March 2000 and December 2005. To determine the sensitivity and specificity of MIOM techniques used to monitor spinal cord and nerve root function during cervical spine surgery. It is appreciated that complication rate of cervical spine surgery is low, however, there is a significant risk of neurological injury. The combination of monitoring of ascending and descending pathways may provide more sensitive and specific results giving immediate feedback information and/or alert regarding any neurological changes during the operation to the surgeon. Intraoperative somatosensory spinal and cerebral evoked potentials combined with continuous EMG and motor-evoked potentials of the spinal cord and muscles were evaluated and compared with postoperative clinical neurological changes. A total of 246 consecutive patients with cervical pathologies, majority spinal stenosis due to degenerative changes of cervical spine were monitored by means of MIOM during the surgical procedure. About 232 patients presented true negative while 2 patients false negative responses. About ten patients presented true positive responses where neurological deficit after the operation was predicted and two patients presented false positive findings. The sensitivity of MIOM applied during cervical spine procedure (anterior and/or posterior) was 83.3% and specificity of 99.2%. MIOM is an effective method of monitoring the spinal cord functional integrity during cervical spine surgery and can help to reduce the risk of neurological deficit by alerting the surgeon when monitoring changes are observed.

Multimodal intraoperative monitoring (MIOM) during 409 lumbosacral surgical procedures in 409 patients

A prospective study on 409 patients who received multimodel intraoperative monitoring (MIOM) during lumbosacral surgical procedures between March 2000 and December 2005 was carried out. The objective of this study was to determine the sensitivity and specificity of MIOM techniques used to monitor conus medullaris, cauda equina and nerve root function during lumbosacral decompression surgery. MIOM has increasingly become important to monitor ascending and descending pathways, giving immediate feedback information regarding any neurological deficit during the decompression and stabilisation procedure in the lumbosacral region. Intraoperative spinal- and cortical-evoked potentials, combined with continuous EMG- and motor-evoked potentials of the muscles, were evaluated and compared with postoperative clinical neurological changes. A total of 409 consecutive patients with lumbosacral spinal stenosis with or without instability were monitored by MIOM during the entire surgical procedure. A total of 388 patients presented true-negative findings while two patients presented false negative and 1 patient false-positive findings. Eighteen patients presented true-positive findings where neurological deficit after the operation was intraoperatively predicted. Of the 18 true-positive findings, 12 patients recovered completely; however, 6 patients recovered only partially. The sensitivity of MIOM applied during decompression and fusion surgery of the lumbosacral region was calculated as 90%, and the specificity was calculated as 99.7%. On the basis of the results of this study, MIOM is an effective method of monitoring the conus medullaris, cauda equina and nerve root function during surgery at the lumbosacral junctions and might reduce postoperative surgical-related complications and therefore improve the long-term results.

A comparative effectiveness study of patient-rated and radiographic outcome after 2 types of decompression with fusion for spondylotic myelopathy: anterior cervical discectomy versus corpectomy

OBJECT Both anterior cervical discectomy with fusion (ACDF) and anterior cervical corpectomy with fusion (ACCF) are used to treat cervical spondylotic myelopathy; however, there is currently no evidence for the superiority of one over the other in terms of patient-rated outcomes. This comparative effectiveness study compared the patient-rated and radiographic outcomes of 2-level ACDF versus 1-level ACCF. METHODS This single-center study was nested within the EuroSpine Spine Tango data acquisition system. Inclusion criteria were the following: consecutive patients presenting with signs of cervical spondylotic myelopathy who underwent 2-level ACDF or 1-level ACCF between 2004 and 2011. Before and 12 months after surgery, patients completed the multidimensional Core Outcome Measures Index (COMI) and also rated global treatment outcome and satisfaction with care on 5-point Likert scales. Cervical lordosis, segmental height, and fusion rate were assessed radiographically before and immediately after surgery and at the last follow-up (20.4 ± 13.7 months, mean ± SD). RESULTS In total, 118 consecutive patients (80 in the ACDF group and 38 in the ACCF group) were included. Age, sex, comorbidity, baseline symptoms, baseline radiographic data, operation duration, and complication rates did not differ significantly between the 2 groups. Blood loss was significantly (p < 0.04) lower in the ACDF group. Postoperative mean segmental height was significantly (p = 0.0006) greater for ACDF (42.0 ± 4.2 mm, mean ± SD) than for ACCF (39.0 ± 4.0 mm), and global average lordosis improved to a significantly (p = 0.003) greater extent in ACDF (by 1.6° ± 4.1°) than in ACCF (by -1.0° ± 4.0°). Fusion rates for ACDF were 97.5% and for ACCF were 94.7% (p = 0.59). The 12-month patient-rated outcomes did not differ significantly between ACDF and ACCF: 82.4% and 68.6% had a good global outcome (operation helped/helped a lot) (p = 0.10), 86.5% and 82.9% were satisfied/very satisfied with care (p = 0.62), and the reduction in the multidimensional COMI was 2.8 ± 2.7 and 2.2 ± 3 points (p = 0.30), respectively. The postoperative increase in lordosis angle showed low but significant correlations with the improvement in arm pain (r = 0.25, p = 0.014), highest pain (r = 0.25, p = 0.013), and function (r = 0.24, p = 0.016). CONCLUSIONS Both ACDF and ACCF are safe and effective in the treatment of cervical spondylotic myelopathy, indicated by similarly good patient-rated outcomes 1 year after surgery. This precludes any conclusions regarding the superiority of one technique over the other, although it should be noted that ACDF resulted in less blood loss and greater improvements in cervical lordosis and segmental height than ACCF. Patients with improved lordosis angle had a better clinical outcome.

Intraarticular atlantooccipital fusion for the treatment of traumatic occipitocervical dislocation in a child: A new technique for selective stabilization with nine years follow-up

Study Design. A case report of traumatic atlantooccipital dislocation (AOD) managed by intraarticular-posterior fusion from a posterior approach at the C0-C1 level with preservation of C1-C2 motion. Objective. To present a new technique for atlantooccipital fusion with long-term follow-up. Summary of Background Data. There is an increasing number of patients with AOD who have preservation of neurologic function. The most frequent method used to treat this condition is occipitocervical fusion. There has been a tendency in recent years to minimize the extent of stabilization, performing occipitoatlantal fusion only. However, it is difficult to achieve a solid fusion between C0 and C1, and the long-term effect of the insufficiency of lig. alaria on C0-C2 stability is unknown. The authors present a modified technique of C0-C1 fusion that aims to enhance fusion and achieve greater stability. Methods. A 11-year-old child with AOD was initially treated unsuccessfully with a halo device for 3 months. As instability persisted, an isolated C0-C1 fusion was performed from a posterior approach. This anatomically based intraarticular fusion technique comprises removal of the articular cartilage of the atlantooccipital joints, and cancellous bone autografting at the atlantooccipital joints and between the occiput and posterior arch of C1, supported by an occipital plate linked by rods to lateral mass screws in the atlas. Results. This technique of increased bony fusion surface and internal fixation provided an excellent result with full recovery of minor neurologic deficits. At long-term follow-up, 9 years after surgery, the patient was free of signs and symptoms; solid fusion of the C0-C1 joint, and normal values for rotation of the C1-C2 segment were recorded. Conclusion. Intraarticular and posterior fusion of the atlantooccipital joint was able to provide an excellent long-term clinical outcome in the treatment of traumatic AOD in a child. This is the first report of an intraarticular fusion of the C0-C1 segment and the longest follow-up published on isolated C0-C1 stabilization.

Could Less Be More When Assessing Patient-rated Outcome in Spinal Stenosis?

Study Design. Longitudinal study of the measurement properties of a brief outcome instrument. Objective. In patients undergoing surgery for lumbar spinal stenosis, we compared the responsiveness of the Core Outcome Measures Index (COMI) with that of the condition-specific Swiss Spinal Stenosis Measure (SSM), an instrument developed to assess patients with neurogenic claudication. Summary of Background Data. The COMI is a validated multidimensional questionnaire for assessing the key outcomes of importance to patients with back problems. Being brief, it is associated with minimal respondent burden and high completion rates. However, for a given pathology, intuitively it may be expected to be less responsive than a condition-specific instrument. Methods. A total of 91 patients (73 ± 8 yr; 53% males) completed the following questionnaires before surgery: COMI, SSM, Roland Morris Disability Questionnaire, back trouble “Feeling Thermometer,” pain numeric rating scale, EuroQoL-visual analogue scale. Twelve months postoperatively, 78/91 (86%) completed all the questionnaires again; they also rated the “global treatment outcome” (GTO; rated 1–5) and SSM “satisfaction with treatment result” (SSM-sat; rated 1–4), which were used as external criteria of treatment success. Results. Scores for the external criteria of success (GTO/SSM-sat) correlated with the change scores (baseline to 12 mo) in COMI (r = 0.57) and SSM (r = 0.54) to a similar extent. Using receiver operating characteristics, with GTO or SSM-sat dichotomized as external criterion, the area under the curve was similar for the COMI change score (0.86–0.90) and the SSM (sub)scales (0.80–0.90). Conclusion. With either SSM-sat or GTO serving as the external criterion, COMI was as responsive as the SSM. The COMI is well able to detect important change in lumbar spinal stenosis and has the added benefit of reducing the response burden for the patient and facilitating outcome comparisons with other spinal pathologies. Level of Evidence: 2