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Renaud Lafage, Ibrahim Obeid, Barthelemy Liabaud, Shay Bess, Douglas Burton, Justin S. Smith, Cyrus Jalai, Richard Hostin, Christopher I. Shaffrey, Christopher Ames, Han Jo Kim, Eric Klineberg, Frank Schwab, Virginie Lafage and the International Spine Study Group

performed by use of logistical regression and stratification to obtain 2 groups of equal numbers of patients without significant differences in age, preoperative alignment, or total correction within the lumbar spine. Global and segmental changes in sagittal alignment were then compared between PJK and noPJK patients using a paired t-test. Finally, substratified groups based on the location of the UIV (lower thoracic, UIV between L1 and T8; upper thoracic, UIV between T7 and T1) were also analyzed in a similar way. Results Patient Population The study population included

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clinical differences will develop. Neurosurg Focus Neurosurgical Focus FOC 1092-0684 American Association of Neurological Surgeons 2013.1.FOC-LSRSABSTRACTS Poster Abstract Poster 3. Use Of Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) Without Iliac Crest Bone Graft In Posterolateral Lumbar Spine Fusion (PLF) Daniel K. Park , MD , Sung Soo Kim , and Scott Boden , MD William Beaumont Hospital, Orthopedic Surgery, Southfield, MI 1 2013 34 1 The Science of Neurosurgical Practice A2

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A1 Copyright held by the American Association of Neurological Surgeons. You may not sell, republish, or systematically distribute any published materials without written permission from JNSPG. 2014 Introduction The objective of this study is to examine the long-term outcomes of patients undergoing non-instrumented posterolateral fusion of the lumbar spine. Methods We present 376 patients who underwent in situ, non-instrumented arthrodesis for lumbar degenerative disease over a 20-year period at a single institution. Patients were followed for an

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SP was widest at 11.09 ± 2.85 mm. L5 had a slope of 23.68 ± 10.51 degrees relative to the mechanical axis, which was steeper than other levels. At L2-L5, more SPs have convex morphology. Conversely, L1 exhibits convex morphology only 38.7% of the time ( Table 1 ). Discussion: Past studies have examined the quantitative anatomy of the lumbar spine as it pertains to pedicle fixation for posterior spinal fusions. Little work, however, has been done to examine lumbar spinous processes and their variable morphology. Spinous process length, width, height and slope

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Christopher I. Shaffrey and Justin S. Smith

Lower back pain and pain involving the area of the posterior iliac spine are extremely common. Degeneration of the sacroiliac joint (SIJ) is one potential cause for lower back pain and pain radiating into the groin or buttocks. Degenerative changes to the lumbar spine and sacroiliac joints are common. A recent study evaluating SIJ abnormalities in a primary low back pain population demonstrated 31.7% of patients demonstrated SI joint abnormalities.4 As is the case for the evaluation and management of isolated lower back pain, the evaluation, management, and role for surgical intervention in SIJ pain is very controversial.

Many patients have degenerative changes of the disc, facet joints, and SIJs. A recent systematic review performed to determine the diagnostic accuracy of tests available to clinicians to identify the disc, facet joint, or SIJ as the source of low back pain concluded that tests do exist that change the probability of the disc or SIJ (but not the facet joint) as the source of low back pain.3 It was also concluded that the usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear.3

Although there is general agreement that SIJ pathological changes are a potential cause of pain, there is far less agreement about the optimal management of these conditions. A variety of conditions can cause SIJ dysfunction including degenerative and inflammatory arthritis, trauma, prior lumbosacral fusion, hip arthritis, limb length inequality, infections, and neoplasia.8 There is increasing evidence that image intensifier-guided single periarticular injection can correctly localize pain to the SIJ but the optimal management strategy remains controversial. Recent publications have compared surgical versus injection treatments and fusion versus denervation procedures.1,8 A systematic review found improvement regardless of the treatment, with most studies reporting over 40% improvement in pain as measured by VAS or NRS scores.8 It cautioned that one of the studies reported 17.6% of patients experiencing mild/no pain compared with 82.4% experiencing marked/severe pain at 39 months after SIJ fusion procedures.6,8 This systematic review also noted that despite improvements in reported pain, less than half of patients who had work status reported as returning to work.8

Because of the functional and socioeconomic consequences of chronic lower back pain, numerous surgical treatments to improve this condition have been attempted by spinal surgeons through the years. Arthrodesis of the SIJ is a surgical procedure with a long history dating to the beginnings of spinal surgery.7 Poor results, high complication rates and the need for additional surgical procedures have generally diminished the enthusiasm for this procedure until recently.6

A variety of “minimally invasive” procedures have been recently introduced that have rekindled enthusiasm for the surgical management of SIJ pathology. The technique demonstrated in the “Stabilization of the SIJ with SI-Bone” is one of these new techniques. There has been a recent publication detailing the very short term clinical outcomes with this technique that reported encouraging results.5 In this series of 50 patients, quality of life questionnaires were available for 49 patients preoperatively, 41 patients at 3 months, 40 at 6 months and only 27 at 12 months, complicating the ability to accurately assess true outcomes.

Although the focus of this video by Geisler is on the surgical technique, there should have been more information provided on the expected surgical outcomes and potential complications of SIJ fusion.2 The video only gives minimal information on how to appropriately select patients with potential SIJ pathology for surgical intervention. There are insufficient recommendations on the clinical and radiographic follow-up needed for this procedure. A concern with this implant is whether the porous plasma spray coating on the implant actually results in bone growth across the SIJ or only serves as a stabilizer. If true fusion does not result, deterioration in the clinical result could occur over time.

This video nicely demonstrates the surgical technique of stabilization of the SIJ with SI-Bone product. There are numerous unanswered questions regarding patient selection for SIJ fusion or stabilization. There are an increasing number of surgical techniques for treating SIJ pathology and it is not clear which method may provide the best outcomes. Without prospective trials with nonconflicted surgeons and standardized selection criteria, the true role for SIJ fusion procedures in the management of chronic lower back pain will remain murky. The consequences of the unsupported enthusiasm for the surgical management of discogenic back pain still negatively impacts the public perception of spinal surgeons. Much more high quality information is needed regarding the surgical management of SIJ pathology before widespread use of this technique should be adopted.

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Dean Chou, Justin S. Smith and Cynthia T. Chin

demonstrated a large right-sided discal cyst extending from L-5 to S-1 and measuring 12 × 10 × 13 mm ( Fig. 1 ). After Gd administration there was enhancement of a focal anular tear but no enhancement of the cyst itself ( Fig. 2 ). F ig . 1. Sagittal (A) and axial (B and C) T 2 -weighted MR images of the lumbar spine demonstrating a large cyst originating from the right L5–S1 disc. Note the tear along the right dorsal L5–S1 anulus fibrosus (arrows) . The cyst is seen to displace the right S-1 root (asterisk) . F ig . 2. Sagittal (A) and axial (B and C) Gd

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Christopher I. Shaffrey and Justin S. Smith

revision lumbar surgery in elderly patients with symptomatic adjacent-segment disease, recurrent stenosis, or pseudarthrosis”) is a study that provides some interesting perspectives on the surgical management of more complex disorders of the lumbar spine in older patients. 3 This study evaluated factors affecting clinical outcomes in 69 patients undergoing revision neural decompression and instrumented fusion for adjacent-segment disease (ASD), pseudarthrosis, or same-level recurrent stenosis. 3 An important aspect of this study was the inclusion of the Zung self

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Christopher I. Shaffrey and Justin S. Smith

Bone morphogenetic protein (BMP) has been increasingly used in the US for a wide range of spinal fusion procedures because of the potential surgical and postsurgical benefits it provides and the perceived reduction in complications related to iliac crest bone graft harvesting. 10 Recombinant human BMP-2 (rhBMP-2, contained in INFUSE Bone Graft, Medtronic Spine and Biologics) has received premarket approval by the FDA for fusion of the lumbar spine in skeletally mature patients with degenerative disc disease at 1 level from L-2 to S-1 and for healing of

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Justin S. Smith, Alfred T. Ogden and Richard G. Fessler

-up, ranging from 12 to 24 months, there was no evidence of construct failure or loosening. Three patients with burst fractures were noted to have angular settling of < 5º, although each of these patients showed a net improvement in segmental kyphosis when supine injury radiographs were compared with follow-up radiographs of patients in the standing position. Ringel and colleagues 63 reported on their extensive experience with minimally invasive transmuscular pedicle screw fixation of the thoracic and lumbar spine that included implantation of 115 internal fixators and

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Christopher I. Shaffrey and Justin S. Smith

medications directly attributed to spine problems increased 188%. 8 Despite these substantial increases in resource utilization, there was no evidence of improvement in self-assessed health status corresponding to these interventions. 8 The present study by Parker and colleagues 12 evaluated 150 patients with degenerative lumbar spine disease (spondylolisthesis in 50; stenosis in 50; and disc herniation in 50) who were managed nonoperatively at a single comprehensive spine center over a 12-month period. Similar to the study by Glassman and associates, 6 Parker and