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Complete anatomic reduction and monosegmental fusion for lumbar spondylolisthesis of Grade II and higher: use of the minimally invasive “rocking” technique

Deshpande V. Rajakumar, Akshay Hari, Murali Krishna, Ankit Sharma, and Manjunatha Reddy

OBJECTIVE

Different surgical approaches have been described for treatment of spondylolisthesis, including in situ fusions, reductions of various degrees, and inclusion of healthy adjacent segments into the fusion construct. To the authors’ knowledge, there are only sparse reports describing consistent complete reduction and monosegmental transforaminal lumbar interbody fusion for spondylolisthesis using a minimally invasive technique. The authors assess the efficacy of this technique in the reduction of local deformity and correction of overall sagittal profile in single-level spondylolisthesis.

METHODS

This cohort study consists of a total of 36 consecutive patients treated over a period of 6 years. Patients with varying grades of lumbar spondylolisthesis (29 Meyerding Grade II and 7 Meyerding Grade III) were treated with operative reduction via minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in which the “rocking” technique was used. The clinical outcomes were measured using the visual analog scale (VAS) for pain and the Revised Oswestry Disability Index (ODI) for low-back pain/dysfunction. Meyerding grade, pelvic incidence (PI), lumbar lordosis (LL), disc space angle (DSA), pelvic tilt (PT), and sacral slope (SS) were assessed to measure the radiological outcomes. These were reviewed for each patient for a minimum of 2 years.

RESULTS

At most recent follow-up, 94% of patients were pain free. There were 2 patients (6%) who had moderate pain (which corresponded to higher-grade of listhesis), but all showed an improvement in pain scores (p < 0.05). The mean VAS score improved from 6.5 (SD 1.5) preoperatively to 1.6 (SD 1.3) and the mean ODI score improved from 53.7 (SD 13.1) preoperatively to 22.5 (SD 15.5) at 2-year follow-up.

All radiological parameters improved following surgery. Most significant improvement was noted for LL, DSA, and SS. Both LL and SS were found to decrease, while DSA increased postoperatively. PI remained relatively unchanged, while PT showed a mild increase, which was not significant. Good fusion was achieved with implants in situ at 2-year follow-up. A 100% complete reduction of all grades of spondylolisthesis was achieved. The overall sagittal profile improved dramatically. No major perioperative complications were encountered.

CONCLUSIONS

Minimally invasive monosegmental TLIF for spondylolisthesis reduction using this rocking technique is effective in the treatment of various grades of spondylolisthesis. Consistent complete reduction of the slippage as well as excellent correction of overall sagittal profile can be achieved, and the need for including healthy adjacent segments in the fusion construct can be avoided.

Free access

Two-level cervical arthroplasty using a “no-distraction” technique

Deshpande Rajakumar, Ankit Sharma, Akshay Hari, Subhas Konar, and Murali Krishna

Cervical arthroplasty is being recognized as an emerging alternative to anterior cervical fusion with comparable or superior outcomes. The authors describe the surgical nuances of 2-level cervical arthroplasty in a case of 2-level degenerative disease. In this surgical technique, conventional vertebral body distraction has been avoided to prevent facet distraction, which can be a cause of persistent postoperative neck pain. Good motion preservation was observed at the 1-year follow-up examination.

The video can be found here: https://youtu.be/YTpRVRXuZZk.

Free access

Adjacent-level arthroplasty following cervical fusion

Deshpande V. Rajakumar, Akshay Hari, Murali Krishna, Subhas Konar, and Ankit Sharma

OBJECTIVE

Adjacent-level disc degeneration following cervical fusion has been well reported. This condition poses a major treatment dilemma when it becomes symptomatic. The potential application of cervical arthroplasty to preserve motion in the affected segment is not well documented, with few studies in the literature. The authors present their initial experience of analyzing clinical and radiological results in such patients who were treated with arthroplasty for new or persistent arm and/or neck symptoms related to neural compression due to adjacent-segment disease after anterior cervical discectomy and fusion (ACDF).

METHODS

During a 5-year period, 11 patients who had undergone ACDF anterior cervical discectomy and fusion (ACDF) and subsequently developed recurrent neck or arm pain related to adjacent-level cervical disc disease were treated with cervical arthroplasty at the authors' institution. A total of 15 devices were implanted (range of treated levels per patient: 1–3).

Clinical evaluation was performed both before and after surgery, using a visual analog scale (VAS) for pain and the Neck Disability Index (NDI). Radiological outcomes were analyzed using pre- and postoperative flexion/extension lateral radiographs measuring Cobb angle (overall C2–7 sagittal alignment), functional spinal unit (FSU) angle, and range of motion (ROM).

RESULTS

There were no major perioperative complications or device-related failures. Statistically significant results, obtained in all cases, were reflected by an improvement in VAS scores for neck/arm pain and NDI scores for neck pain. Radiologically, statistically significant increases in the overall lordosis (as measured by Cobb angle) and ROM at the treated disc level were observed. Three patients were lost to follow-up within the first year after arthroplasty. In the remaining 8 cases, the duration of follow-up ranged from 1 to 3 years. None of these 8 patients required surgery for the same vertebral level during the follow-up period.

CONCLUSIONS

Artificial cervical disc replacement in patients who have previously undergone cervical fusion surgery appears to be safe, with encouraging early clinical results based on this small case series, but more data from larger numbers of patients with long-term follow-up are needed. Arthroplasty may provide an additional tool for the management of post-fusion adjacent-level cervical disc disease in carefully selected patients.

Open access

Variations in management of A3 and A4 cervical spine fractures as designated by the AO Spine Subaxial Injury Classification System

Barry Ting Sheen Kweh, Jin Wee Tee, Sander Muijs, F. Cumhur Oner, Klaus John Schnake, Lorin Michael Benneker, Emiliano Neves Vialle, Frank Kanziora, Shanmuganathan Rajasekaran, Gregory Schroeder, Alexander R. Vaccaro, and the AO Spine Subaxial Injury Classification System Validation Group, Andrey Grin MD Ahmed Shawky Abdelgawaad MD Akbar Jaleel Zubairi FCOS Ortho Alejandro Castillo MD Alejo Vernengo Lezica MD Alessandro Ramieri MD, PhD Alfredo Guiroy MD Alon Grundshtein MD Amauri Godinho Jr. MD Amin Henine MD Andrei A. Pershin MD, PhD Alkinoos Athanasiou MD, PhD Baron Zarate-Kalfopulos MD Sofien Benzarti MD Claudio Bernucci MD Brandon J. Rebholz MD, FAAOS, Bruno Direito-Santos MS, MSc, FEBOT, Bruno Lourenço Costa MD, MSc, Bruno Saciloto MD, Catalin Majer MD, PhD, Chadi Tannoury MD, FAOA, FAAOS, Christina Cheng MD, Jason Pui Yin Cheung MD, Christian Konrads MD, Chumpon Jetjumnong MD, Chun Kee Chung MD, PhD, Eugen Cezar Popescu MD, PhD, Cumhur Kilinçer MD, PhD, Colin B. Harrism MD, FAAOS, Craig D. Steiner MD, Cristina Igualada MD, Darko Perovic MD, PhD, David Ruiz Picazo MD, Luis David Orosco Falcone MD, Dilip Gopalakrishnan MS, Desai Ankit MBBS, D.Ortho, DNB (Ortho), Devi Prakash Tokala FRCS (T&O), Balgopal Karmacharya FCPS, Raphael Lotan MD, MHA, Mahmoud Shoaib MSc, Salvatore Russo FRCS (NS), Arun Kumar iswanadha MS, FACS, Bhavuk Garg MS (Ortho), Noe Dimas Uribe CMOT, Fabricio Medina MD, Jayakumar Subbiah DNB (Ortho), Wael Alsammak MD, Valentine Mandizvidza FCS-ECSA (Ortho), Ahmad Arieff Atan MD, Rathinavelu Barani MS (Ortho), MRCS (Ed), Hugo Vilchis Sámano MD, Emilija Stojkovska Pemovska MD, Fabian Catarino Lopez Hinojosa MD, Taolin Fang MD, PhD, Federico Landriel MD, Federico Daniel Sartor PhD, Marcus Vinicius De Oliveira Ferreira MD, Vito Fiorenza MD, Francisco Alberto Mannara MD, Seibert Franz Prof. Dr. Mag., Brett A. Freedman MD, Samuel Arsenio M. Grozman MD, FPOA, FPCS, Guillermo Espinosa MD, Guillermo Alejandro Ricciardi MD, Gunaseelan Ponnusamy MS (Ortho) UKM, Hassane Ali Amadou MD, Itati Romero MD, Joost Rutges MD, PhD, James Harrop MD, MSHQS, Jose-Carlos Sauri-Barraza MD, Jeevan Kumar Sharma MBBS, MS (Ortho), FASSI, Jose Joefrey F. Arbatin Jr. FPOA, Jeronimo B. Milano MD, PhD, Jibin Joseph Francis (SA) FRCS (SN), John Chen Li Tat MB BCh (NUI), BAO, LRCSI, FRCS (Ed), Joachim Vahl MD, Jose Alfredo Corredor MD, João Moreno Morais MD, Joana Guasque MD, John Koerner MD, Duerinck Johnny MD, PhD, Jose Rafael Perozo Ron MD, Juan Delgado-Fernandez MD, Juan Esteban Muñoz Montoya Juan Lourido MD, Ariel Kaen PhD, Kubilay Murat Özdener MD, Konstantinos Margetis MD, PhD, Konstantinos Paterakis MD, Lady Lozano Cari MD, Lingjie Fu MD, PhD, Ahmed Dawoud MD, Luis Muñiz Luna MD, Mahmoud Alkharsawi PhD, Maximo-Alberto Diez-Ulloa MD, Maria A. García-Pallero MD, Mauro Pluderi MD, PhD, Marcelo Gruenberg MD, Marcelo Valacco MD, Mario Ganau MD, PhD, MBA, FEBNS, Martin M. Estefan MD, Luis Miguel Duchén Rodríguez MD, Naohisa Miyakoshi MD, PhD, Mahmoud Elshamly MD, PhD, Mohamed Fawzy Khattab MD, PhD, Sean R. Smith MD, Mbarak Abeid MD, Ignacio Garfinkel MD, Nicola Nicassio MD, Nuno Neves PhD, Olga Carolina Morillo Acosta MD, Pedro Luis Bazán MD, Paulo Pereira MD, PhD, Phedy Lim MD, Patrick R. Pritchard MD, Pragnesh Bhatt MS, MCh, FRCS, FEBNS, Raghuraj Kundangar MS (Ortho), Rian Souza Vieira MD, Ricardo Rodrigues-Pinto MD, PhD, Ripul R. Panchal DO, FACOS, FACS, Rafael Llombart-Blanco MD, PhD, Ronald Alberto Rioja Rosas MD, Rui Manilha MD, Ratko Yurac MD, Sara Diniz MD, Scott C. Wagner MD, Segundo Fuego MD, Selvaraj Ramakrishnan MD, Serdar Demiröz MD, Shafiq Hackla MBBS, MS (Ortho), DNB (Ortho), Babak Shariati FRCS, Mohammad El-Sharkawi MD, PhD, Yasunori Sorimachi MD, DMSc, PhD, Stipe Corluka MD, Sung-Joo Yuh MD, Thami Benzakour MD, Tarek ElHewala MD, PhD, Tarun Suri MS, FNB (Spine surgery), Derek T. Cawley MMSc, MCh, FRCS, Adetunji Toluse MD, FWACS, FMCOrtho, Cristian Valdez MD, Waheed Abdul MD, Waqar Hassan MD, Yohan Robinson MD, PhD, MBA, Zachary L. Hickman MD, FAANS, Mohamad Zaki Haji Mohd Amin MS Ortho, Oscar González Guerra MD, Zdenek Klezl MD, PhD,

OBJECTIVE

Optimal management of A3 and A4 cervical spine fractures, as defined by the AO Spine Subaxial Injury Classification System, remains controversial. The objectives of this study were to determine whether significant management variations exist with respect to 1) fracture location across the upper, middle, and lower subaxial cervical spine and 2) geographic region, experience, or specialty.

METHODS

A survey was internationally distributed to 272 AO Spine members across six geographic regions (North America, South America, Europe, Africa, Asia, and the Middle East). Participants’ management of A3 and A4 subaxial cervical fractures across cervical regions was assessed in four clinical scenarios. Key characteristics considered in the vignettes included degree of neurological deficit, pain severity, cervical spine stability, presence of comorbidities, and fitness for surgery. Respondents were also directly asked about their preferences for operative management and misalignment acceptance across the subaxial cervical spine.

RESULTS

In total, 155 (57.0%) participants completed the survey. Pooled analysis demonstrated that surgeons were more likely to offer operative intervention for both A3 (p < 0.001) and A4 (p < 0.001) fractures located at the cervicothoracic junction compared with fractures at the upper or middle subaxial cervical regions. There were no significant variations in management for junctional incomplete (p = 0.116) or complete (p = 0.342) burst fractures between geographic regions. Surgeons with more than 10 years of experience were more likely to operatively manage A3 (p < 0.001) and A4 (p < 0.001) fractures than their younger counterparts. Neurosurgeons were more likely to offer surgical stabilization of A3 (p < 0.001) and A4 (p < 0.001) fractures than their orthopedic colleagues. Clinicians from both specialties agreed regarding their preference for fixation of lower junctional A3 (p = 0.866) and A4 (p = 0.368) fractures. Overall, surgical fixation was recommended more often for A4 than A3 fractures in all four scenarios (p < 0.001).

CONCLUSIONS

The subaxial cervical spine should not be considered a single unified entity. Both A3 and A4 fracture subtypes were more likely to be surgically managed at the cervicothoracic junction than the upper or middle subaxial cervical regions. The authors also determined that treatment strategies for A3 and A4 subaxial cervical spine fractures varied significantly, with the latter demonstrating a greater likelihood of operative management. These findings should be reflected in future subaxial cervical spine trauma algorithms.

Restricted access

2017 AANS Annual Scientific Meeting Los Angeles, CA • April 22–26, 2017

Free access

Abstracts of the 2017 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves Las Vegas, Nevada • March 8–11, 2017