Robert W. Molinari

Complications in the surgical treatment of pediatric high-grade, isthmic dysplastic spondylolisthesis. A comparison of three surgical approaches.

STUDY DESIGN An analysis of consecutive pediatric patients treated surgically for high-grade spondylolisthesis by one of three surgical procedures with emphasis on complications and functional outcomes. OBJECTIVE Complications, radiographic results and patient-assessed function, pain, and satisfaction were assessed among three surgical procedures. SUMMARY OF BACKGROUND DATA The existing literature is in disagreement about whether it is better to fuse without instrumented reduction or to use instrumentation and reduce high-grade dysplastic spondylolisthesis. METHODS Thirty-two patients had 37 surgical procedures for Meyerding Grade 3 or 4 isthmic dysplastic spondylolisthesis. Eleven patients were treated with an in situ L4-sacrum posterior fusion without decompression (Group 1), 7 had posterior decompression with posterior instrumentation and posterior fusion (Group 2), and 19 patients had reduction and a circumferential fusion procedure (Group 3). All patients had new radiographs taken at time of follow-up (average, 3.1 years; range, 2 years-10 years, 1 month) and completed a functional outcome questionnaire. RESULTS The incidence of pseudarthrosis was 45% (5 of 11) in Group 1, 29% (2 of 7) in Group 2, and 0% (0 of 19) in Group 3. All seven who had pseudarthrosis had small L5 transverse process surface area (< 2 cm2; P = 0.004). Only one patient had a neurologic deficit (unilateral extensor hallucis longus weakness) at time of follow-up. There were no significant differences among the groups in function, pain, and satisfaction in patients in whom solid fusion was obtained, but the scores were highest in Group 3. CONCLUSIONS In situ fusion surgery in patients with high-grade spondylolisthesis with small L5 transverse processes (surface area, < 2 cm2) results in a high rate of pseudarthrosis. Circumferential procedures result in the highest rate of fusion and are effective in achieving fusion in those patients with established pseudarthrosis. The use of long (> 60 mm) iliac screws bilaterally (n = 21) in addition to bicortical sacral screws (four-point sacral-pelvis fixation) along with anterior column fusion reduces the risk of instrumentation failure in a decompression and reduction procedure. Outcomes of function, pain, and satisfaction are excellent in those in whom fusion is achieved. The risks in circumferential fusion-reduction procedures are acceptable.

Posterior lumbar interbody fusion.

Abstract Posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) create intervertebral fusion by means of a posterior approach. Both techniques are useful in managing degenerative disk disease, severe instability, spondylolisthesis, deformity, and pseudarthrosis. Successful results have been reported with allograft, various cages (for interbody support), autograft, and recombinant human bone morphogenetic protein‐2. Interbody fusion techniques may facilitate reduction and enhance fusion. The rationale for PLIF and TLIF is biomechanically sound. However, clinical outcomes of different anterior and posterior spinal fusion techniques tend to be similar. PLIF has a high complication rate (dural tear, 5.4% to 10%; neurologic injury, 9% to 16%). These findings, coupled with the versatility of TLIF throughout the entire lumbar spine, may make TLIF the ideal choice for an all‐posterior interbody fusion.

Minimum 5-year follow-up of anterior column structural allografts in the thoracic and lumbar spine

STUDY DESIGN An analysis of consecutive adult patients treated surgically with anterior column structural allografts for sagittal plane abnormalities. OBJECTIVES To evaluate the effectiveness of anterior structural allografts in maintaining long-term sagittal plane correction when combined with posterior spinal fusion and posterior segmental spinal instrumentation and to assess anterior allograft incorporation into adjacent vertebral bodies a minimum of 5 years after implantation. SUMMARY OF BACKGROUND DATA There is no study in the literature in which incorporation and remodeling of anterior column structural allografts with minimum 5-year follow-up are assessed. Do they collapse or resorb or sustain stress fractures between a 2-year and 5-year follow-up? METHODS Twenty-three consecutive adult patients (mean age, 45 years; range, 25-63 years) had a combination of anterior structural fresh-frozen allograft plus posterior autogenous grafting and posterior segmental spinal instrumentation performed from June 1988 through August 1992. All patients had sagittal plane abnormalities, and all surgeries were performed by the same surgeon. Twenty of the 23 patients returned for follow-up examinations for at least 5 years (average, 7 +/- 3 years; range, 5 +/- 4-10 +/- 3 years). Diagnoses included kyphoscoliosis (n = 8), spondylolisthesis (n = 3), degenerative disc disease (n = 3), and acute or chronic fracture (n = 6). The allografts spanned only disc spaces in 16 patients, and vertebral bodies and disc spaces in 4 patients. Forty disc spaces and four vertebral bodies were grafted, and 67 structural allografts were placed. Upright radiographs were analyzed before surgery, immediately after surgery, and at final follow-up examination to assess the degree of anterior allograft incorporation and maintenance of sagittal correction. A strict 4-point grading system was used. Two independent observers, not involved with surgical procedures, analyzed the radiographic results. RESULTS Of the 67 structural allografts, 66 (98.5%) showed incorporation. Both observers concluded that none of the 67 structural allografts showed evidence of collapse. In all grafted levels and in any patient, there was no difference in sagittal plane measurements obtained immediately after surgery and those obtained at follow-up examinations 2 years and 5 or more years after surgery. CONCLUSIONS Anterior fresh-frozen structural allograft works effectively in the long term to maintain correction of sagittal plane abnormalities if combined with posterior fusion and instrumentation. A minimum of 5 years after surgery, there is a high rate of structural allograft incorporation into the adjacent vertebral bodies.

Anterior column support in surgery for high-grade, isthmic spondylolisthesis.

The literature is confusing as to the need for anterior column fusion in the surgical treatment of patients with high-grade dysplastic spondylolisthesis. The current authors present an analysis of consecutive pediatric patients treated surgically for high-grade spondylolisthesis with and without anterior column structural support with emphasis on fusion rates, segmental kyphosis correction, and functional outcomes. Thirty-seven surgical procedures were done in 31 patients for Meyerding Grade 3 or Grade 4 isthmic dysplastic spondylolisthesis. Patients were separated into two groups based on whether they had structural anterior column support (tricortical autogenous iliac crest) in addition to posterior fusion surgery. Group 1 consisted of 18 patients treated only with posterior surgery without anterior structural support (11 patients were treated with L4-sacrum posterior in situ fusion and seven patients were treated with posterior instrumented reduction with decompression and posterior fusion), and Group 2 consisted of 19 patients who had a reduction and circumferential fusion including anterior structural support. All patients had new radiographs taken at the time of followup (average, 3.1 years, range, 2 years–10 years 1 month) and completed a functional outcome questionnaire. The incidence of pseudarthrosis was 39% (seven of 18 patients) in Group 1 and 0% (0 of 19) in Group 2. All seven patients who had pseudarthrosis achieved solid fusion with a second procedure involving circumferential fusion with anterior column structural grafting. Outcomes regarding pain after treatment, function, and satisfaction were high in those patients who achieved solid fusion regardless of surgical procedure.

Cervical spine injury severity score. Assessment of reliability.

BACKGROUND Systems for classifying cervical spine injury most commonly use mechanistic or morphologic terms and do not quantify the degree of stability. Along with neurologic function, stability is a major determinant of treatment and prognosis. The goal of our study was to investigate the reliability of a method of quantifying the stability of subaxial (C3-C7) cervical spine injuries. METHODS A quantitative system was developed in which an analog score of 0 to 5 points is assigned, on the basis of fracture displacement and severity of ligamentous injury, to each of four spinal columns (anterior, posterior, right pillar, and left pillar). The total possible score thus ranges from 0 to 20 points. Fifteen examiners assigned scores after reviewing the plain radiographs and computed tomography images of thirty-four consecutive patients with cervical spine injuries. The scores were then evaluated for interobserver and intraobserver reliability with use of intraclass correlation coefficients. RESULTS The mean intraobserver and interobserver intraclass correlation coefficients for the fifteen reviewers were 0.977 and 0.883, respectively. Association between the scores and clinical data was also excellent, as all patients who had a score of > or =7 points had surgery. Similarly, eleven of the fourteen patients with a score of > or =7 points had a neurologic deficit compared with only three of the twenty with a score of <7 points. CONCLUSIONS The Cervical Spine Injury Severity Score had excellent intraobserver and interobserver reliability. We believe that quantifying stability on the basis of fracture morphology will allow surgeons to better characterize these injuries and ultimately lead to the development of treatment algorithms that can be tested in clinical trials.

Fusion versus nonoperative care for chronic low back pain: do psychological factors affect outcomes?

Study Design. Systematic review. Objective. The objectives of this systematic review were to determine whether fusion is superior to conservative management in certain psychological subpopulations and to determine the most common psychological screening tests and their ability to predict outcome after treatment in patients with chronic lower back pain. Summary of Background Data. Many studies have documented the effects of various psychological disorders on outcomes in the treatment of lower back pain. The question of whether patients with certain psychological disorders would benefit more from conservative treatment than fusion is not clear. Furthermore, the most appropriate screening tools for assessing psychological factors in the presence of treatment decision making should be recommended. Methods. Systematic review of the literature, focused on randomized controlled trials to assess the heterogeneity of treatment effect of psychological factors on the outcomes of fusion versus nonoperative care of the treatment of chronic low back pain. In the analysis of psychological screening tests, we searched for the most commonly reported questionnaires and those that had been shown to predict lower back pain treatment outcomes. Results. Few studies comparing fusion to conservative management reported differences in outcome by the presence or absence of a psychological disorder. Among those that did, we observed the effect of fusion compared with conservative management was more favorable in patients without a personality disorder, neuroticism, or depression. The most commonly reported, validated psychological screening tests for lower back pain are the Beck Depression Inventory, the Fear Avoidance Belief Questionnaire, the Spielberger Trait Anxiety Inventory, the Zung Depression Scale, and the Distress Risk Assessment Method. Conclusion. Psychological disorders affect chronic lower back pain treatment outcomes. Patients with a personality disorder appear to respond more favorably to conservative management and those without a personality disorder more favorably to fusion. Patients with higher depression and neuroticism scores may also respond more favorably to conservative management. Clinical Recommendations.Recommendation 1: Chronic LBP patients with depression, neuroticism, and certain personality disorders should preferentially be treated nonoperatively. Strength of recommendation: Weak.Recommendation 2: Consider the use of a validated psychological screening questionnaire such as the BDI, FABQ, DRAM, ZDI or STAI, when treating patients with CLBP. Strength of recommendation: Weak.

Functional Outcomes, Morbidity, Mortality, and Fracture Healing in 26 Consecutive Geriatric Odontoid Fracture Patients Treated With Posterior Fusion

Study Design: Retrospective review. Objective: To evaluate functional outcomes, fracture healing, complications, and mortality associated with posterior fusion surgery (PSF) for the management of geriatric type II odontoid fractures. Summary of Background Data: Outcomes of C1-2 fusion for geriatric odontoid fractures are not well defined. Methods: Twenty-six consecutive elderly patients with type II odontoid fractures were treated by the same spinal surgeon at a Level-1 trauma center during an 8-year period. All patients had ≥50% odontoid displacement and were treated with PSF including C1-2 (PSF group; average age, 79 y). Chart reviews were performed evaluating patient comorbidities, treatment complications, and mortality rates. At ultimate follow-up, patients had open mouth, flexion, and extension radiographs to assess fracture stability and healing. In addition, functional outcomes were assessed using Neck Disability Index (NDI), analog pain, and satisfaction questionnaire scores and compared with a group of 40 aged-matched control patients (control group; average age, 79.8 y). Results: The mortality rate was 19.2%, and major complications occurred in 27% of patients. At an average 13-month follow-up (range, 3–48 mo), the fracture-healing rate was only 33%. However, no patient had mobile odontoid nonunion or instability of the C1-2 articulation. NDI scores averaged 18.1 points indicating only mild residual disability. Pain scores were low averaging only 1.8 points. NDI and pain scores did not differ significantly from aged-matched controls (P=0.16). Treatment satisfaction scores were high. Odontoid nonunion was not associated with significantly higher levels of disability or neck pain and did not affect scores for patient satisfaction. Conclusions: PSF for geriatric odontoid fractures is associated with moderately high levels of morbidity and mortality. Posttreatment neck pain and disability is low and does not differ significantly from aged-matched cohorts. Odontoid fracture healing after surgical stabilization does not correlate with improved functional outcomes.

Low-grade isthmic spondylolisthesis treated with instrumented posterior lumbar interbody fusion in U.S. servicemen.

Purpose: The existing literature lacks a functional outcomes study addressing instrumented posterior lumbar fusion surgery for isthmic spondylolisthesis in physically active patients. Presently, spinal surgeons can provide only anecdotal advice when discussing operative outcomes with these patients. This is a nonrandomized analysis of consecutive military servicemen treated operatively for chronic back pain and low-grade isthmic spondylolisthesis with single-level lumbar disc degeneration with emphasis on functional outcomes. The purpose was to evaluate patient-assessed function/pain/satisfaction and military job performance in U.S. servicemen treated with posterior lumbar interbody fusion (PLIF). Methods: Thirty consecutive U.S. military servicemen with chronic low back pain and low-grade lumbar isthmic spondylolisthesis were referred to the same surgeon at a military treatment facility. All servicemen were treated operatively with instrumented PLIF using autogenous iliac crest bone graft, one or two nonthreaded interbody cages (Brantigan or Harms), and a four-pedicle screw/rod construct. A concomitant bilateral posterolateral fusion was performed in all 30 cases. The average follow-up time was 15 months (range 12-48 months). Twenty-five of the 30 servicemen completed a functional outcomes questionnaire (American Academy of Orthopaedic Surgeons/Scoliosis Research Society) with emphasis on pre- and posttreatment function, pain, and satisfaction. The servicemen were also evaluated using standard military job performance parameters. Results: Three of the 30 servicemen (10%) requested and received a disability discharge from the military for back pain that continued throughout the postoperative period and prevented return to military duty. An additional 8 of the original 30 soldiers (27%) required some form of permanent physical activity limitation (situps/pushups/running/lifting) to permit their return to military duty, and 19 of 30 (63%) soldiers were able to return to full and unrestricted military duty after surgery. Those soldiers who were able to return to unrestricted military duty (n = 19) did so at an average of 6 months post treatment (range 2-16 months). Of the soldiers who were able to return to military duty, 21 of 30 (70%) were able to complete the posttreatment military physical fitness test at an average of 8 months postoperatively (range 2-32 months). No significant differences were observed between premorbid and postsurgical physical fitness test scores. There was a trend toward lower postsurgical scores. Complications included dural tear (n = 4), unilateral transient lower extremity paresthesia (n = 1), and wound seroma requiring reoperation (n = 1). Conclusions: In this nonrandomized study of 30 U.S. servicemen with chronic low back pain, low-grade isthmic spondylolisthesis, and single-level lumbar disc degeneration, instrumented PLIF surgery was associated with a high rate of return to functional military duty. Outcomes with respect to posttreatment pain, function, and satisfaction were high in patients treated with instrumented PLIF.

Functional outcomes, morbidity, mortality, and fracture healing in 58 consecutive patients with geriatric odontoid fracture treated with cervical collar or posterior fusion.

Controversy exists as to the most effective management option for elderly patients with type II odontoid fractures. The purpose of this study is to evaluate outcomes associated with rigid cervical collar and posterior fusion surgery. Patients with ≥ 50% odontoid displacement were treated with posterior fusion surgery including C1–2 (PSF group, n = 25, average age = 80 years). Patients with < 50% odontoid displacement were treated with a rigid cervical collar for 12 weeks (collar group, n = 33, average age = 83 years). These inhomogeneous groups were followed for an average of 14 months. Fracture healing rates were higher in the operative group (28% versus 6%). Neck Disability Index scores were slightly lower in the nonoperative group (13 versus 18.3, p = 0.23). Analogue pain scores were also slightly lower in the nonoperative group (1.3 versus 1.9, p = 0.26). The mortality rate was 12.5% in the collar group and 20% in the operative group. Complications were higher in the operative group (24% versus 6%). Rates of type II odontoid facture healing and stability appear to be higher in geriatric patients treated with posterior fusion surgery. Fracture healing and stability did not correlate with improved outcomes with respect to levels of pain, function, and satisfaction. Mortality and complication rates are lower in those patients with lesser-displaced fractures who are treated with a cervical collar and early mobilization.

Anterior cervical discectomy and fusion with structural allograft and plates for the treatment of unstable posterior cervical spine injuries

OBJECT The purpose of this study was to evaluate complications and radiographic and functional outcomes of isolated anterior stabilization surgery in which structural allograft and plates were used for posterior unstable subaxial cervical spine lateral mass, facet, and ligamentous injuries. METHODS Between August 2003 and January 2008, 19 consecutive patients with unstable lateral mass, facet, and/or posterior ligamentous injuries of the subaxial cervical spine were treated by a single surgeon via an anterior approach. This was performed using structural allograft and plate fixation. Patients with any associated anterior vertebral fractures were excluded from the study. Autogenous bone grafts or bone graft substitutes were not used in any patient. The average age of the patients was 43 years (range 17-87 years) and the mean follow-up period was 20.4 months (range 6-48 months). Seventeen of the 19 patients participated in the study; the other 2 were lost to follow-up. Operative times, estimated blood loss, length of hospital stay (LOS), and perioperative complications were recorded for each patient. Radiographic outcomes included fusion scores and sagittal alignment measurements. Outcome scores with respect to neck pain, satisfaction with surgery, and function were recorded for each patient according to analog pain and satisfaction scales and the Neck Disability Index (NDI). Additionally, NDI and pain scores at final follow-up were compared with a group of healthy, age-matched controls. RESULTS The average surgical time was 60 minutes (range 28-108 minutes), and the estimated blood loss averaged 48.9 ml per surgical procedure (range 20-150 ml). The LOS for the 13 patients who had no other associated injuries averaged 2.2 days (range 2-3 days). Fifteen of 17 patients achieved solid radiographic fusion, and no patient demonstrated instability. Only 1 patient had significant loss of the initial sagittal alignment correction at final follow-up. The average NDI score for the 17 patients was 6.5 (range 0-11), indicating mild disability and comparing favorably to a group of healthy age-matched controls. There was no statistical difference in pain scores for the trauma patients and control group at ultimate follow-up (1.5 vs 0.3, respectively). Satisfaction scores for the 17 trauma patients were high, averaging 94% (range 80-100%). Ten of the 11 patients with preoperative radiculopathy demonstrated complete resolution of this condition. Complications occurred in 1 patient with transient hoarseness and 1 with transient swallowing difficulty. There were no wound complications. Screw breakage occurred in 1 patient, and an additional patient required revision surgery for pseudarthrosis. CONCLUSIONS Anterior cervical discectomy and fusion performed using interbody structural allograft and plate fixation is highly effective in the treatment of unstable posterior cervical lateral mass, facet, and ligamentous injuries. This treatment option results in low intraoperative blood loss, short operating times, and a brief LOS. Radiographic outcomes with respect to segmental stability are excellent, and fusion rates with the use of structural allograft alone are high. Outcomes with respect to pain, function, and patient satisfaction are high, and complications are acceptably low.