Friederike Lattig

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.

Bone cement augmentation in the prevention of adjacent segment failure after multilevel adult deformity fusion.

Study Design Prospective case report series and detailed description of technique. Objectives To describe a surgical procedure designed to prevent fracture and cutting-through and pullout of screws in the adjacent segment after multilevel deformity correction in adults. Summary of Background Data Surgery of adult deformities has a high complication rate. One of the potential late complications is the development of fracture at the first mobile segment above a multilevel lumbar or thoracolumbar spinal fusion that necessitates further surgical intervention with extension of the instrumentation. Augmentation with bone cement of the last instrumented vertebra and the first mobile vertebra has the potential to prevent this pathology. Methods Three patients with degenerative thoracolumbar kyphoscoliosis and 3 with adjacent segment failure after correction surgery were treated. Cannulated and perforated pedicle screws were placed in the uppermost-instrumented vertebra. A vertebroplasty tube was inserted from 1 side at the center of the first mobile vertebra. Under C-arm control, vertebroplasty was performed in both vertebrae. Results Intraoperatively, there were no cement-related complications. Follow-ups at 6 and 12 (±2) months revealed there was no loss of correction, fracture or screw loosening in the augmented vertebrae. Conclusions Bone cement augmentation of the uppermost screws and the first mobile vertebra in multilevel adult deformity and revision surgery seems to be a safe and potentially effective method of preventing adjacent segment failure.

Treatment of Early Onset Spinal Deformity (EOSD) with VEPTR: A Challenge for the Final Correction Spondylodesis: A Case Series.

Study Design:Case Series. Objective:To describe the post-VEPTR (vertical expandable prosthetic titanium rib) treatment changes in early-onset spinal deformity (EOSD), which may influence the final correction spondylodesis. Summary of Background Data:The VEPTR device, originally developed for the treatment of congenital rib cage malformation, is nowadays more widely used in the treatment of EOSD. At present, only a few reports describe the possible complications that may occur with repeated lengthening procedures of the VEPTR, thereby making the final spondylodesis more complicated and less satisfactory. Methods:X-rays of 5 children treated for EOSD with 2 unilateral VEPTR (each rib to rib and rib to lumbar lamina) were analyzed for curve patterns and Cobb angles before, during, and at the end of VEPTR treatment, and after the final spondylodesis. Intraoperative observations during the spondylodesis, which influenced the possibilities of the curve correction, were documented. Results:All patients showed a marked decompensation of the frontal balance and a high degree of rigidity of the main curve and the compensatory curves after treatment with the VEPTR device. Because of this spontaneous autofusion of spinal segments, migration of the rib cradles and/or the laminar hook, and a change in the curve patterns, the final fusion had to be longer in all patients than the primary deformity would have intended. Conclusions:If an EOSD is treated with VEPTR, the curve progression and, in particular, the development of a high thoracic hyperkyphosis or rotation of the main curve should be critically observed. Autofusion of ribs and vertebral bodies may make the final correction spondylodesis even more challenging and risky for the patient and the end result less satisfactory.

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.

Lumbar facet joint effusion on MRI as a sign of unstable degenerative spondylolisthesis: should it influence the treatment decision?

Study Design: Retrospective study. Objective: To examine whether the outcomes of decompression alone (D) or decompression with fusion (D&F) differed depending on the presence or absence of the facet effusion sign in degenerative spondylolisthesis. Summary of Background Data: There is ongoing discussion as to whether D&F is superior to D in the surgical treatment of patients with lumbar degenerative spondylolisthesis (LDS) and symptoms of spinal or radicular claudication. Previous studies have shown that a positive facet joint effusion sign on magnetic resonance imaging correlates with the spontaneous reduction of slip when comparing upright and supine postures and might represent a sign of instability, guiding treatment decisions. Patients and Methods: One hundred sixty patients [age 69 (SD 10) y; 119 women, 41 men] with a diagnosis of LDS were identified retrospectively from our Spine Center Registry (linked to the Eurospine, Spine Society of Europe Spine Tango Registry). They were categorized based on the presence/absence of the facet effusion sign and the type of treatment received. Forty-four patients had effusion and underwent D; 76 effusion and D&F; 19 no effusion and D; and 21 no effusion and D&F. Before surgery and 3, 12, and 24 months after surgery, patients completed the multidimensional Core Outcome Measures Index questionnaire. At follow-up, they rated the global treatment outcomes (1–5 scale). Multiple regression analyses evaluated the factors influencing the outcomes. Results: When age and sex was controlled for, there was no significant difference in outcomes dependent on the presence of the facet effusion sign and/or the treatment received (D vs. D&F). Conclusions: Although mindful of the limitations of this retrospective study, we conclude that the effusion sign alone does not seem to be an indication for adding fusion to decompression in the treatment of LDS. Hence, the presence of the facet effusion sign should not, in itself, deter the surgeon from performing decompression alone. However, the phenomenon should be investigated in larger samples of patients, ideally within a randomized trial.

Management of fractures of the pedicle after instrumentation with transpedicular screws: A REPORT OF THREE PATIENTS

Fracture of a pedicle is a rare complication of spinal instrumentation using pedicular screws, but it can lead to instability and pain and may necessitate extension of the fusion. Osteosynthesis of the fractured pedicle by cerclage-wire fixation and augmentation of the screw fixation by vertebroplasty or temporary elongation of the fixation, allows stabilisation without sacrifice of the adjacent healthy segment. We describe three patients who developed a fracture of the pedicle in the most caudal instrumented vertebra early after lumbar spinal fusion. During revision surgery the pedicles were reduced and secured by a soft cerclage wire bilaterally. Fusion was obtained at the site of the primary instrumentation and healing of the pedicles was achieved. Cerclage wiring of the fractured pedicle seems to be safe and avoids permanent extension of the fusion without the sacrifice of an otherwise healthy segment.