Peng-Yuan Chang, Hsuan-Kan Chang and Jau-Ching Wu
Peng-Yuan Chang and Michael Y. Wang
In minimally invasive spinal fusion surgery, transforaminal lumbar (sacral) interbody fusion (TLIF) is one of the most common procedures that provides both anterior and posterior column support without retraction or violation to the neural structure. Direct and indirect decompression can be done through this single approach. Preoperative plain radiographs and MR scan should be carefully evaluated. This video demonstrates a standard approach for how to perform a minimally invasive transforaminal lumbosacral interbody fusion.
The video can be found here: https://youtu.be/bhEeafKJ370.
Michael Y. Wang, Peng-Yuan Chang and Jay Grossman
Over the past decade, Enhancing Recovery After Surgery (ERAS) programs have been implemented throughout the world across multiple surgical disciplines. However, to date no spinal surgery equivalent has been described. In this report the authors review the development and implementation of a “fast track” surgical approach for lumbar fusion.
The first 42 consecutive cases in which patients were treated with the new surgical procedure were reviewed. A combination of endoscopic decompression, expandable cage deployment, and percutaneous screw placement were performed with liposomal bupivacaine anesthesia to allow the surgery to be performed without general endotracheal anesthesia.
In all cases the surgical procedure was performed successfully without conversion to an open operation. The patients' mean age (± SD) was 66.1 ± 11.7 years, the male/female ratio was 20:22, and a total of 47 levels were treated. The mean operative time was 94.6 ± 22.4 minutes, the mean intraoperative blood loss was 66 ± 30 ml, and the mean hospital length of stay was 1.29 ± 0.9 nights. Early follow-up showed a significant improvement in the mean Oswestry Disability Index score (from 40 ± 13 to 17 ± 11, p = 0.0001). Return to the operating room was required in 2 cases due to infection and in 1 case due to cage displacement. An iterative quality improvement program demonstrated areas of improvement, including steps to minimize infection, improve postoperative analgesia, and reduce cage osteolysis.
ERAS programs for improving spinal fusion surgery are possible and necessary. This report demonstrates a first foray to apply these principles through 1) a patient-focused approach, 2) reducing the stress of the operation, and 3) an iterative improvement process.
Hsuan-Kan Chang, Chih-Chang Chang, Tsung-Hsi Tu, Jau-Ching Wu, Wen-Cheng Huang, Li-Yu Fay, Peng-Yuan Chang, Ching-Lan Wu and Henrich Cheng
Many reports have successfully demonstrated that cervical disc arthroplasty (CDA) can preserve range of motion after 1- or 2-level discectomy. However, few studies have addressed the extent of changes in segmental mobility after CDA or their clinical correlations.
Data from consecutive patients who underwent 1-level CDA were retrospectively reviewed. Indications for surgery were medically intractable degenerative disc disease and spondylosis. Clinical outcomes, including visual analog scale (VAS)–measured neck and arm pain, Neck Disability Index (NDI), and Japanese Orthopaedic Association (JOA) scores, were analyzed. Radiographic outcomes, including C2–7 Cobb angle, the difference between pre- and postoperative C2–7 Cobb angle (ΔC2–7 Cobb angle), sagittal vertical axis (SVA), the difference between pre- and postoperative SVA (ΔSVA), segmental range of motion (ROM), and the difference between pre- and postoperative ROM (ΔROM), were assessed for their association with clinical outcomes. All patients underwent CT scanning, by which the presence and severity of heterotopic ossification (HO) were determined during the follow-up.
A total of 50 patients (mean age 45.6 ± 9.33 years) underwent a 1-level CDA (Prestige LP disc) and were followed up for a mean duration of 27.7 ± 8.76 months. All clinical outcomes, including VAS, NDI, and JOA scores, improved significantly after surgery. Preoperative and postoperative ROM values were similar (mean 9.5° vs 9.0°, p > 0.05) at each indexed level. The mean changes in segmental mobility (ΔROM) were −0.5° ± 6.13°. Patients with increased segmental mobility after surgery (ΔROM > 0°) had a lower incidence of HO and HO that was less severe (p = 0.048) than those whose ΔROM was < 0°. Segmental mobility (ROM) was significantly lower in patients with higher HO grade (p = 0.012), but it did not affect the clinical outcomes. The preoperative and postoperative C2–7 Cobb angles and SVA remained similar. The postoperative C2–7 Cobb angles, SVA, ΔC2–7 Cobb angles, and ΔSVA were not correlated to clinical outcomes after CDA.
Segmental mobility (as reflected by the mean ROM) and overall cervical alignment (i.e., mean SVA and C2–7 Cobb angle) had no significant impact on clinical outcomes after 1-level CDA. Patients with increased segmental mobility (ΔROM > 0°) had significantly less HO and similarly improved clinical outcomes than those with decreased segmental mobility (ΔROM < 0°).
Hsuan-Kan Chang, Huang-Chou Chang, Jau-Ching Wu, Tsung-Hsi Tu, Li-Yu Fay, Peng-Yuan Chang, Ching-Lan Wu, Wen-Cheng Huang and Henrich Cheng
The aim of this paper was to investigate the risk of recurrence of lumbar disc herniation (LDH) in patients with scoliosis who underwent microdiscectomy.
A series of consecutive patients who underwent microdiscectomy for LDH was retrospectively reviewed. The inclusion criteria were young adults younger than 40 years who received microdiscectomy for symptomatic 1-level LDH. An exclusion criterion was any previous spinal surgery, including fusion or correction of scoliosis. The patients were divided into 2 groups: those with scoliosis and those without scoliosis. The demographic data in the 2 groups were similar. All medical records and clinical and radiological evaluations were reviewed.
A total of 58 patients who underwent 1-level microdiscectomy for LDH were analyzed. During the mean follow-up of 24.6 months, 6 patients (10.3%) experienced a recurrence of LDH with variable symptoms. The recurrence rate was significantly higher among the scoliosis group than the nonscoliosis group (33.3% vs 2.3%, p = 0.001). Furthermore, the recurrence-free interval in the scoliosis group was short.
Young adults (< 40 years) with uncorrected scoliosis are at higher risk of recurrent LDH after microdiscectomy.
Chih-Chang Chang, Li-Yu Fay, Jau-Ching Wu, Peng-Yuan Chang, Tsung-Hsi Tu, Henrich Cheng and Wen-Cheng Huang
Quan-chang Tan, Jian-wei Wu, Fei Peng, Yuan Zang, Yang Li, Xiong Zhao, Wei Lei and Zi-xiang Wu
This study investigated the optimum injection volume of polymethylmethacrylate (PMMA) to augment a novel fenestrated pedicle screw (FPS) with diameter-tapered perforations in the osteoporotic vertebral body, and how the distribution characteristics of PMMA affect the biomechanical performance of this screw.
Two types of FPSs were designed (FPS-A, composed of 6 perforations with an equal diameter of 1.2 mm; and FPS-B, composed of 6 perforations each with a tapered diameter of 1.5 mm, 1.2 mm, and 0.9 mm from tip to head. Each of 28 human cadaveric osteoporotic vertebrae were randomly assigned to 1 of 7 groups: FPS-A1.0: FPS-A+1.0 ml PMMA; FPS-A1.5: FPS-A+1.5 ml PMMA; FPS-A2.0: FPS-A+2.0 ml PMMA; FPS-B1.0: FPS-B+1.0 ml PMMA; FPS-B1.5: FPS-B+1.5 ml PMMA; FPS-B2.0: FPS-B+2.0 ml PMMA; and conventional pedicle screws (CPSs) without PMMA. After the augmentation, 3D CT was performed to assess the cement distribution characteristics and the cement leakage rate. Axial pullout tests were performed to compare the maximum pullout force thereafter.
The CT construction images showed that PMMA bone cement formed a conical mass around FPS-A and a cylindrical mass around FPS-B. When the injection volume was increased from 1.0 ml to 2.0 ml, the distribution region of the PMMA cement was enlarged, the PMMA was distributed more posteriorly, and the risk of leakage was increased. When the injection volume reached 2.0 ml, the risk of cement leakage was lower for screws having diameter-tapered perforations. The pullout strengths of the augmented FPS-A groups and FPS-B groups were higher than that of the CPS group (p < 0.0001). All FPS-B groups had a higher pullout strength than the FPS-A groups.
The diameter of the perforations affects the distribution of PMMA cement. The diameter-tapered design enabled PMMA to form larger bone-PMMA interfaces and achieve a relatively higher pullout strength, although statistical significance was not reached. Study results indicated 1.5-ml of PMMA was a conservative volume for PMMA augmentation; more cement injection would significantly increase the risk of cement leakage.
Yu-Shu Yen, Peng-Yuan Chang, Wen-Cheng Huang, Jau-Ching Wu, Muh-Lii Liang, Tsung-Hsi Tu and Henrich Cheng
The goal of the study was to report a series of consecutive patients who underwent endoscopic transnasal odontoidectomy (ETO) without resection of nasal turbinates. The techniques for this minimally invasive approach are described in detail.
The authors conducted a retrospective review of consecutive patients who underwent ETO for basilar invagination. All the patients had myelopathy caused by compression at the cervicomedullary junction, which required surgical decompression. Preoperative and postoperative data, including those from radiographic and clinical evaluations, were compared. Morbidity and mortality rates for the procedure are also reported in detail.
Thirteen patients (6 men and 7 women) with a mean age of 52.7 years (range 24–72 years) were enrolled. The basilar invagination etiologies were rheumatoid arthritis (n = 5), trauma (n = 4), os odontoideum (n = 2), ankylosing spondylitis (n = 1), and postinfectious deformity (n = 1). The average follow-up duration was 51.2 months (range 0.3–105 months). One patient died 10 days after the operation as a result of meningitis caused by CSF leakage. Among the other 12 patients, the average postoperative Nurick grade (3.2) was significantly improved over that before the operation (4.1, p = 0.004). The mean (± SD) duration of postoperative intubation was 1.5 ± 2.1 days, and there was no need for perioperative tracheostomy or nasogastric tube feeding. There also was no postoperative velopharyngeal insufficiency. There were 6 (46%) intraoperative and 2 (15%) postoperative CSF leaks in the 13 patients in this series.
ETO is a viable and effective option for decompression at the ventral cervicomedullary junction. This approach is minimally invasive and causes little velopharyngeal insufficiency. The pitfall of this approach is the difficulty in repairing dural defects and subsequent CSF leakage.
Wen-Cheng Huang, Jau-Ching Wu, Peng-Yuan Chang, Tsung-Hsi Tu, Yu-Shu Yen and Henrich Cheng
Peng-Yuan Chang, Hsuan-Kan Chang, Jau-Ching Wu, Wen-Cheng Huang, Li-Yu Fay, Tsung-Hsi Tu, Ching-Lan Wu and Henrich Cheng
Several large-scale clinical trials demonstrate the efficacy of 1- and 2-level cervical disc arthroplasty (CDA) for degenerative disc disease (DDD) in the subaxial cervical spine, while other studies reveal that during physiological neck flexion, the C4–5 and C5–6 discs account for more motion than the C3–4 level, causing more DDD. This study aimed to compare the results of CDA at different levels.
After a review of the medical records, 94 consecutive patients who underwent single-level CDA were divided into the C3–4 and non-C3–4 CDA groups (i.e., those including C4–5, C5–6, and C6–7). Clinical outcomes were measured using the visual analog scale for neck and arm pain and by the Japanese Orthopaedic Association scores. Postoperative range of motion (ROM) and heterotopic ossification (HO) were determined by radiography and CT, respectively.
Eighty-eight patients (93.6%; mean age 45.62 ± 10.91 years), including 41 (46.6%) female patients, underwent a mean follow-up of 4.90 ± 1.13 years. There were 11 patients in the C3–4 CDA group and 77 in the non-C3–4 CDA group. Both groups had significantly improved clinical outcomes at each time point after the surgery. The mean preoperative (7.75° vs 7.03°; p = 0.58) and postoperative (8.18° vs 8.45°; p = 0.59) ROMs were similar in both groups. The C3–4 CDA group had significantly greater prevalence (90.9% vs 58.44%; p = 0.02) and higher severity grades (2.27 ± 0.3 vs 0.97 ± 0.99; p = 0.0001) of HO.
Although CDA at C3–4 was infrequent, the improved clinical outcomes of CDA were similar at C3–4 to that in the other subaxial levels of the cervical spine at the approximately 5-year follow-ups. In this Asian population, who had a propensity to have ossification of the posterior longitudinal ligament, there was more HO formation in patients who received CDA at the C3–4 level than in other subaxial levels of the cervical spine. While the type of artificial discs could have confounded the issue, future studies with more patients are required to corroborate the phenomenon.