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1.
Oxygen Embolism and Pneumocephalus After Hydrogen Peroxide Application During Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery: A Case Report and Literature Review.
Zou, P, Yang, JS, Wang, XF, Wei, JM, Guo, H, Zhang, B, Zhang, F, Chu, L, Hao, DJ, Zhao, YT
World neurosurgery. 2020;:201-204
Abstract
BACKGROUND Hydrogen peroxide (H2O2) solution is commonly used to irrigate wounds because of its hemostatic and antiseptic properties. Previous studies suggest that H2O2 can result in toxicity to keratinocytes and fibroblasts, but complications after H2O2 application, including oxygen embolism, which is one of the most severe, have rarely been reported. CASE DESCRIPTION A 40-year-old woman was diagnosed with L4-5 lumbar spinal stenosis and subsequently underwent minimally invasive transforaminal lumbar interbody fusion treatment at another hospital. Hypotension, hypoxia, and a decrease in end-tidal carbon dioxide pressure occurred immediately after H2O2 irrigation. After the operation, she was able to be extubated but remained comatose. Postoperative computed tomography scan revealed intracranial air trapping in the right frontal lobe and multiple cerebral infarction foci. CONCLUSIONS When using a knee-prone surgical position or in cases of dural laceration, the application of undiluted H2O2 solution should be avoided, especially in a surgical wound within a closed cavity. When hypotension, hypoxia, and a decrease in end-tidal carbon dioxide pressure occur immediately after H2O2 irrigation, oxygen embolism should be strongly suspected.
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Clinical and biomechanical researches of polyetheretherketone (PEEK) rods for semi-rigid lumbar fusion: a systematic review.
Li, C, Liu, L, Shi, JY, Yan, KZ, Shen, WZ, Yang, ZR
Neurosurgical review. 2018;(2):375-389
Abstract
Lumbar spinal fusion using rigid rods is a common surgical technique. However, adjacent segment disease and other adverse effects can occur. Dynamic stabilization devices preserve physiologic motion and reduce painful stress but have a high rate of construct failure and reoperation. Polyetheretherketone (PEEK) rods for semi-rigid fusions have a similar stiffness and adequate stabilization power compared with titanium rods, but with improved load sharing and reduced mechanical failure. The purpose of this paper is to review and evaluate the clinical and biomechanical performance of PEEK rods. A systematic review of clinical and biomechanical studies was conducted. A literature search using the PubMed, EMBASE, and Cochrane Library databases identified studies that met the eligibility criteria. Eight clinical studies and 15 biomechanical studies were included in this systematic review. The visual analog scale and the Oswestry disability index improved significantly in most studies, with satisfactory fusion rates. The occurrence of adjacent segment disease was low. In biomechanical studies, PEEK rods demonstrated a superior load-sharing distribution, a larger adjacent segment range of motion, and reduced stress at the rod-screw/screw-bone interfaces compared with titanium rods. The PEEK rod construct was simple to assemble and had a reliable in vivo performance compared with dynamic devices. The quality of clinical studies was low with confounding results, although results from mechanical studies were encouraging. There is no evidence strong enough to confirm better outcomes with PEEK rods than titanium rods. More studies with better protocols, a larger sample size, and a longer follow-up time are needed.
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Medical optimization of lumbar fusion in the osteoporotic patient.
Morris, MT, Tarpada, SP, Tabatabaie, V, Cho, W
Archives of osteoporosis. 2018;(1):26
Abstract
PURPOSE In patients undergoing lumbar fusion, osteoporosis has been shown to lead to poorer outcomes and greater incidence of fusion-related complications. Given the undesirable effect of osteoporosis on lumbar fusion surgery, a number of medications have been proposed for use in the peri- and postoperative period to mitigate risks and enhance outcomes. The purpose of this review was to summarize and synthesize the current literature regarding medical management of osteoporosis in the context of lumbar fusion surgery. METHODS A literature search of PubMed, Embase, and Web of Science was conducted in October 2016, using permutations of various search terms related to osteoporosis, medications, and lumbar fusion. RESULTS Teriparatide injections may lead to faster, more successful fusion, and may reduce fusion-related complications. Bisphosphonate therapy likely does not hinder fusion outcomes and may be useful in reducing certain complications of fusion in osteoporotic patients. Calcitonin and selective estrogen receptor modulator therapy show mixed results, but more research is necessary to make a recommendation. Vitamin D deficiency is associated with poor fusion outcomes, but evidence for supplementation in patients with normal serum levels is weak. CONCLUSIONS Overall, the current body of research appears to support the use of teriparatide therapy to enhance lumbar fusion outcomes in the osteoporotic patient, although the extent of research on this topic is limited. Additionally, very little evidence exists to cease any of the mentioned osteoporosis treatments prior to lumbar fusion.
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Pedicle screw augmentation in osteoporotic spine: indications, limitations and technical aspects.
Hoppe, S, Keel, MJ
European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2017;(1):3-8
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Abstract
PURPOSE The need for spinal instrumented fusion in osteoporotic patients is rising. In this review, we try to give an overview of the current spectrum of pedicle screw augmentation techniques, safety aspects and indications. METHODS Review of literature and discussion of indications, limitations and technical aspects. RESULTS Various studies have shown higher failure rates in osteoporotic patients, most probably due to reduced bone quality and a poor bone-screw interface. Augmentation of pedicle screws with bone cement, such as polymethylmethacrylate or calcium based cements, is one valid option to enhance fixation if required. CONCLUSIONS Crucial factors for success in the use of augmented screws are careful patient selection, a proper technique and choice of the ideal cement augmentation option.
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Stem Cells in Spine Surgery.
Hansraj, KK
Surgical technology international. 2016;:348-358
Abstract
INTRODUCTION Spine surgeons are embracing advanced biologic technologies in an attempt to help millions of people achieve a better outcome in spine surgery. These new technologies may be complicated to understand, partly because the contribution of different types of cells has not been definitively identified. This paper describes the characteristics of the stem cells used in spine surgery, including their actions and possible complications. The description necessitates an overview of all studies to date on the use of stem cells in spine surgery, as well as other cells used in cellular therapy. MATERIALS AND METHODS The paper summarizes the results of major studies to date on the use of stem cells in spine surgery. Cells were harvested from the posterior superior iliac spine, vertebral bodies in surgery, fat tissue, or from the posterior spine of cadavers. RESULTS This paper reports on three studies involving 37 patients treated with stem cells for regenerative spine surgery, 14 studies involving 533 patients treated with stem cells in spinal fusion surgery, and one study in which stem cells were used for the treatment of anterior cervical discectomy and fusion. DISCUSSION Indications, techniques, and calibration of results were different in each study. Results are available for cellular augmentation of demineralized bone sponges, OsteoSponge® (Bacterin, Belgrade, Montana) and concentrated bone marrow (Terumo BCT®, Lakewood, CO); cancellous allograft bone and BMA; mineralized collagen and BMA; Osteocel® Plus (OC+) (Nuvasive®, San Diego, California); b-Tricalcium phosphate (b-TCP) (SYNTHES® Dento, West Chester, Pennsylvania; a silicate-substituted calcium phosphate (Si-CaP) with bone marrow aspirate (BMA), and HEALOS® graft carrier (DePuy Synthes, West Chester, Pennsylvania) with bone marrow aspirate. CONCLUSION Stem cell augmentation of spinal fusion surgery is equivalent to the gold standard for iliac crest bone graft in posterolateral fusion models. There is evidence of safety and feasibility in the injectable treatment of DDD with autologous BMC that indicates a favorable outcome of mesenchymal cell concentration on discogenic pain reduction. The use of adult stem cells is an innovation that promises fewer complications and improved function in patients who are demographically suitable for stem cell therapy.
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MIS Expandable Interbody Spacers: A Literature Review and Biomechanical Comparison of an Expandable MIS TLIF With Conventional TLIF and ALIF.
Cannestra, AF, Peterson, MD, Parker, SR, Roush, TF, Bundy, JV, Turner, AW
Spine. 2016;:S44-9
Abstract
STUDY DESIGN Biomechanical study and review of literature on expandable lumbar interbody fusion constructs. OBJECTIVE To evaluate the biomechanical stability of expandable interbody devices. SUMMARY OF BACKGROUND DATA Lumbar interbody implants placed from an anterior or lateral approach are desirable due to their large size, providing a stable fusion environment. Posterior implants are typically limited by their access corridor. Expandable footprint transforaminal lumbar interbody fusion (TLIF) interbodies may allow for a minimally invasive TLIF approach with the biomechanical benefits of an anterior lumbar interbody fusion (ALIF)-sized graft; however, this requires experimental investigation. METHODS Six cadaveric L1-sacrum segments were tested intact with pure moments of ± 7.5 N m in flexion-extension, lateral bending, and axial rotation. Specimens received at L4-5 either a medial-lateral expandable TLIF cage (MLX-TLIF) or a conventional polyether ether ketone (PEEK) banana-shaped TLIF cage (Conv-TLIF) first. Both were tested with unilateral and bilateral pedicle screw (PS) fixation. Testing was repeated with the alternate cage and fixation. Motion marker arrays were fixed to L4 and L5 to assess range of motion. Results were compared with published data for a PEEK ALIF cage with anterior plate and a PEEK ALIF cage with bilateral PS fixation, tested under the same conditions. RESULTS The most rigid construct was ALIF with bilateral PS fixation in flexion-extension and axial rotation, whereas MLX with bilateral PS was most rigid in lateral bending. Conv-TLIF with unilateral PS was the least rigid construct. MLX-TLIF with unilateral PS provided similar range of motion to Conv-TLIF with bilateral PS in flexion-extension and lateral bending, and ALIF with anterior plate in lateral bending. CONCLUSION The MLX-TLIF cage with unilateral PS fixation provided comparable stability to conventional TLIF with bilateral PS fixation and ALIF with anterior plate treatments. The large footprint of the expandable cage may reduce the TLIF supplemental fixation demands and facilitate minimally invasive single-position surgery. If needed, additional stability may be achieved by using bilateral PS. LEVEL OF EVIDENCE N/A.
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Congenital scoliosis in Smith-Magenis syndrome: a case report and review of the literature.
Li, Z, Shen, J, Liang, J, Sheng, L
Medicine. 2015;(17):e705
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Abstract
The Smith-Magenis syndrome (SMS) is a complex and rare congenital condition that is characterized by minor craniofacial anomalies, short stature, sleep disturbances, behavioral, and neurocognitive abnormalities, as well as variable multisystemic manifestations. Little is reported about spinal deformity associated with this syndrome.This study is to present a case of scoliosis occurring in the setting of SMS and explore the possible mechanisms between the 2 diseases.The patient is a 13-year-old Chinese female with congenital scoliosis and Tetralogy of Fallot, mental retardation, obstructive sleep apnea, hypertrophy of tonsil, conductive hearing loss, and agenesis of the epiglottis. An interphase fluorescent in situ hybridization at chromosome 17p11.2 revealed a heterozygous deletion, confirming a molecular diagnosis of SMS. She underwent a posterior correction at thoracic 1-lumbar 1 (T1-L1) levels, using the Moss-SI spinal system. At 6-month follow-up, the patient was clinically pain free and well balanced. Plain radiographs showed solid spine fusion with no loss of correction.Congenital cardiac disease, immunodeficiency, and severe behavioral problems can affect the surgical outcome following spine fusion and need to be taken into consideration for the surgeon and anesthesiologist. Scoliosis is not uncommon among patients with SMS, and there is a potential association between congenital scoliosis and SMS. The potential mechanisms in the pathogenesis of congenital scoliosis of SMS included retinoic acid-induced 1 (RAI1) microdeletion and RAI1 gene point mutation.
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PEEK rod systems for the spine.
Mavrogenis, AF, Vottis, C, Triantafyllopoulos, G, Papagelopoulos, PJ, Pneumaticos, SG
European journal of orthopaedic surgery & traumatology : orthopedie traumatologie. 2014;:S111-6
Abstract
Traditional materials for the spine such as titanium and stainless steel have produced satisfying long-term fusion rates, mainly due to their strength and stiffness. However, although fixation with titanium rods leads to high fusion rates, increased stiffness of titanium constructs may also contribute to stress shielding and adjacent segment degeneration. Dynamic and flexible materials such as the Dynesys system allow better stress distribution to all of the spinal columns, but increase the rate of complications including screw loosening, infection, back and leg pain, and endplate vertebral fracture. Semi-rigid instrumentation systems using rods made from synthetic polymers such as the polyetheretherketone (PEEK) have been recently introduced as an alternative biomaterial for the spine. PEEK is a fully biocompatible and inert semi-crystalline thermoplastic polymer with minimal toxicity; it has a modulus of elasticity between that of cortical and cancellous bone, and significantly lower than titanium. However, there are very few clinical studies with small sample size and short-term follow-up using PEEK rod-pedicle screw spinal instrumentation systems. Additionally, their results are conflicting. To enhance the literature, this review discusses the effect of this medical for the spine and summarizes the results of the most important related series.
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Congential scoliosis in Wilson's disease: case report and review of the literature.
Li, Z, Yu, X, Shen, J, Liang, J
BMC surgery. 2014;:71
Abstract
BACKGROUND Wilson's disease (WD) is an autosomal recessive disorder of copper metabolism, which leads to the accumulation of this metal in liver, brain, cornea and kidney. Little is reported about spinal deformity associated with this syndrome. This study is to present a case of thoracic kyphosis occurring in the setting of Wilson'disease and explore the possible association between the two diseases. CASE PRESENTATION Case report and literature review. A previously unreported thoracic kyphosis in Wislon's disease is decribed. The patient was a 7-year-old Chinese female that underwent a posterior correction, using the Moss-SI spinal system performed at Thoracic 9-Lumbar 1 (T9-L1) levels. At 16-month follow-up, the patient was clinically pain free and well balanced. Plain radiographs showed solid spine fusion with no loss of deformity correction. After evaluating 211 WD patients referred to Peking Union Medical College Hospital from February 1991 to February 2012, the prevalence of congential scoliosis among patients with WD was 5.21% (11/211), much higher than that among general population (1/1000). CONCLUSIONS To the best of our knowledge, this is the first report of WD with thoracic kyphosis. During sugery, surgeons and anesthesiologists must pay particular attention to the abnormal liver and brain function associated with WD. The prevalence of scoliosis is much higher among patients with WD, indicating a potential association between congential scoliosis and WD. However, the exact mechanism how copper-chelating agents induce scoliosis is unclear.
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Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 16: bone graft extenders and substitutes as an adjunct for lumbar fusion.
Kaiser, MG, Groff, MW, Watters, WC, Ghogawala, Z, Mummaneni, PV, Dailey, AT, Choudhri, TF, Eck, JC, Sharan, A, Wang, JC, et al
Journal of neurosurgery. Spine. 2014;(1):106-32
Abstract
In an attempt to enhance the potential to achieve a solid arthrodesis and avoid the morbidity of harvesting autologous iliac crest bone (AICB) for a lumbar fusion, numerous alternatives have been investigated. The use of these fusion adjuncts has become routine despite a lack of convincing evidence demonstrating a benefit to justify added costs or potential harm. Potential alternatives to AICB include locally harvested autograft, calcium-phosphate salts, demineralized bone matrix (DBM), and the family of bone morphogenetic proteins (BMPs). In particular, no option has created greater controversy than the BMPs. A significant increase in the number of publications, particularly with respect to the BMPs, has taken place since the release of the original guidelines. Both DBM and the calciumphosphate salts have demonstrated efficacy as a graft extender or as a substitute for AICB when combined with local autograft. The use of recombinant human BMP-2 (rhBMP-2) as a substitute for AICB, when performing an interbody lumbar fusion, is considered an option since similar outcomes have been observed; however, the potential for heterotopic bone formation is a concern. The use of rhBMP-2, when combined with calcium phosphates, as a substitute for AICB, or as an extender, when used with local autograft or AICB, is also considered an option as similar fusion rates and clinical outcomes have been observed. Surgeons electing to use BMPs should be aware of a growing body of literature demonstrating unique complications associated with the use of BMPs.