Negative Effects of Diffuse Idiopathic Skeletal Hyperostosis on Bone Fusion after Transforaminal Lumbar Interbody Fusion

Hagihara Shusuke,Ohta Hideki,Tanaka Jun,Shiokawa Teruaki,Kida Yoshikuni,Iguchi Yohei,Tatsumi Masato,Shibata Ryo,Tahara Kenichi,Shibata Tatsuya,Sanada Kyoichi,Ymamoto Takuaki 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.5

Study Design: This study adopted a retrospective cohort study design.Purpose: This study aimed to clarify the influence of diffuse idiopathic skeletal hyperostosis (DISH) on bone fusion after transforaminal lumbar interbody fusion (TLIF).Overview of Literature: The negative effects of DISH on lumbar degenerative diseases have been reported, and DISH may be involved in the onset and severity of lumbar spinal canal stenosis. Patients with DISH have significantly more reoperations after posterior lumbar fusion, including TLIF. However, the effects of DISH on bone fusion after TLIF have not been reported.Methods: The medical records of patients with intervertebral TLIF from 2012 to 2018 were retrospectively examined. The patients were divided into those with fusion and those with pseudoarthrosis, and the following data were compared: age, sex, DISH, diabetes mellitus, smoking, drinking, albumin levels, body mass index ≥30 kg/m², and L5/S fixation. Statistical analyses were performed using regression models.Results: In this study, 180 patients (78.6%) had fusion and 49 patients (21.4%) had pseudoarthrosis. The number of patients with DISH was significantly higher in the pseudoarthrosis group than in the fusion group (36.7% and 21.7%, respectively; univariate <i>p</i>=0.031, multivariate p =0.019). No significant differences in age, sex, diabetes mellitus, smoking, drinking, albumin levels, body mass index ≥30 kg/m², and L5/S fixation were observed between the two groups. The risk factors for bone fusion were statistically analyzed in 57 patients with DISH. DISH with a caudal end below Th11 was an independent risk factor for pseudoarthrosis (univariate <i>p</i>=0.011, multivariate <i>p</i>=0.033).Conclusions: DISH is an independent risk factor for pseudoarthrosis after one intervertebral TLIF, and DISH with a caudal end below Th11 is associated with a higher risk of pseudoarthrosis than DISH without a caudal end below Th11.

젊은 역도 선수에게 발생한 양측성 제1늑골의 피로골절: 견부 동통의 드문 원인

김준범 ( Jun Bum Kim ),홍시전 ( Sijohn Hong ) 대한스포츠의학회 2017 대한스포츠의학회지 Vol.35 No.2

Isolated stress fracture of the first rib is quite rare cause of uncertain shoulder pain in athletes. These fractures are stress induced and precipitated by repeated traction of muscles acting on the first rib. A prompt diagnosis can shorten the time required for healing and decrease the risk of associated complication as nonunion or pseudoarthrosis. The diagnosis can be made by taking a thorough history and performing chest X-ray, computed tomography, or bone scan. Early recognition and proper management generally lead to successful outcomes and return to normal activities. Typically, they heal with conservative treatment with rest and mild analgesia. This report describes stress fractures of bilateral first rib in a weightlifter, one of which developed into a pseudoarthrosis as a result of persistent overhead activities due to missed diagnosis.

퇴행성 요추 질환에서 척추경나사 주위 방사선 투과 영역의 임상적 의미

곽종일,김현준,선상규,이규열 대한척추외과학회 2009 대한척추외과학회지 Vol.16 No.3

연구계획: 후향적 연구 연구목적: 본 연구는 퇴행성 요추 질환에서 술 후 척추경나사 주위 방사선 투과 영역의 임상적 의미에 대해 고찰하고 자 한다. 대상 및 방법: 척추경나사 고정술을 시행 받은 399명을 대상으로 술 후 6개월, 1년, 2년 및 3년째 시간 경과에 따른 투과 영역(clear zone)의 발생 여부를 확인하였다. 2가지 이상의 방사선 사진에서 동일 나사 주위 1 mm 이상의 투과 영역이 관찰되면 방사선 투과 영역 양성으로 판단하였다. 그리고 투과 영역 발생과 관련된 인자로서 나이, 수술 받은 척추 분절 수, 골유합 여부, 유합술의 종류, 그리고 재수술 시행 여부와의 상관관계를 분석하였다. 결과: 술 후 6개월 째 124명에서 투과 영역(31.1%)이 발생하였으며, 시간이 경과함에 따라 발생률은 점점 감소하여 술 후 1년째에는 89명(22.3%), 술 후 2년째에는 44명(11.0%), 그리고 술 후 3년째에는 41명(10.3%)에서 나타났다. 술 후 6개월이 지나 새로 발생한 투과 영역은 없었다. 최종 추시 결과에서 가관절증은 12명(3.0%)에서 나타났으며 이중 11명이 투과 영역 양성이었고 1명만이 투과 영역 음성으로 나타났다. 투과 영역 발생과 척추 분절 수간에는 분절수 가 증가 할수록 투과 영역 양성이 많았으며 이는 통계학적으로 유의성이 있었다. 그리고 60세 이상에서 60세 미만에 서 보다 투과 영역 양성률이 높았으며 통계학적으로 유의하였다. 후측방 고정술 및 후방 추체간 유합술을 동시에 시 행한 군에서 후측방 고정술만을 시행한 군에 비해 투과 영역 양성률이 상대적으로 낮았으나 통계학적인 유의성이 없었다. 결론: 척추경 나사못을 이용한 수술 후 나타난 방사선학적 투과 영역이 반드시 병변을 의미하는 것은 아니며 추시 상에도 소실 없이 지속되는 경우엔 가관절증의 발생률이 더욱 높았으며 통계학적으로 유의하였다. Study design: A retrospective study. Objective: To analyze the clinical significance of the radiolucent zones surrounding pedicle screws. Summary of Literature Review: Clear zones have been suggested in pseudoarthrosis and a loss of fixation. However, few reports have clearly described the long-term course and clinical significance of clear zones. Materials and Methods: The clear zones were evaluated in 399 patients with pedicle screw fixation after 6 months, 1 year, 2 years and 3 years. The patient was considered to be clear zone positive when 1 mm or greater circumferential lucency was confirmed around a screw on film from 2 or more directions. The time-course of the clear zones was examined with regard to age, number of levels fused, bone union, fusion method and reoperation. Results: After 6 months, clear zones were observed in 124 patients (31.1%) but the clear zone-positive rate decreased with time. Clear zones were observed in 89 patients(22.3%), 44 patients(11.0%) and 41 patients(10.3%) after 1 year, 2 years and 3 years, respectively. No new clear zones had developed after 6 months. At the final follow-up, pseudoarthrosis was observed in 12 patients(3.0%). Among them, 11 were clear zone-positive and 1 was clear zone-negative. There was a statistically significant relationship between the clear zone-positive rate and multi-levels, older age and nonunion during following up. In addition, there was a relatively lower clear zone-positive rate in posterolateral fusion combined with posterior lumbar interbody fusion than only posterolateral fusion. However, the difference between them was not statistically significant. Conclusion: The presence of clear zones does not always mean pseudoarthrosis but clear zones persisting for more than 2 years after surgery have a higher rate of pseudoarthrosis.

Postoperative Loss of Lumbar Lordosis Affects Clinical Outcomes in Patients with Pseudoarthrosis after Posterior Lumbar Interbody Fusion Using Cortical Bone Trajectory Screw Fixation

Yamagishi Akira,Sakaura Hironobu,Ishii Masayoshi,Ohnishi Atsunori,Ohwada Tetsuo 대한척추외과학회 2021 Asian Spine Journal Vol.15 No.3

Study Design: Retrospective cohort study. Purpose: This study aimed to investigate relationships between clinical outcomes and radiographic parameters in patients with pseudoarthrosis after posterior lumbar interbody fusion (PLIF). Overview of Literature: In some patients with pseudoarthrosis after PLIF, clinical symptoms improve following surgery, although pseudoarthrosis can often be one of the complications. However, there are no previous reports describing differences between patients with pseudoarthrosis after PLIF who have obtained better clinical outcomes and those who have not. Methods: Twenty-seven patients who were diagnosed with pseudoarthrosis after single-level PLIF with cortical bone trajectory screw fixation (CBT-PLIF) were enrolled in this study. They were divided into two groups based on mean improvement of 22 points on the Oswestry Disability Index (ODI) at the 2-year follow-up. Group G consisted of 15 patients who showed improvement on the ODI of ≥22 points, and group P consisted of the residual 12 patients. Radiographic parameters, percentage of slip, lumbar lordosis (LL), segmental lordosis, segmental range of motion, screw loosening, and subsidence were compared between the two groups. Results: There were no significant differences between the two groups on radiographic parameters except for postoperative changes in LL. Although surgery-induced changes in LL showed no significant difference between the two groups, changes in LL from before surgery to 2-year follow-up and during postoperative 2-year follow-up were significantly better in group G (mean change of LL: +3.5° and +5.1°, respectively) compared to group P (mean change of LL: −4.6° and −0.5°, respectively) (p<0.01 and 0.05, respectively). Conclusions: Patients with greater improvement in ODI gained LL over the 2-year follow-up, whereas patients with less improvement in ODI lost LL during the 2-year follow-up. These results indicate that there is a significant correlation between clinical outcomes and LL even in patients with pseudoarthrosis after single-level CBT-PLIF.

Coronal Plane Gap Increases Postoperative Pseudoarthrosis after Lateral Interbody Fusion for Adult Spinal Deformity

Okada Eijiro,Yagi Mitsuru,Yamamoto Yusuke,Suzuki Satoshi,Nori Satoshi,Tsuji Osahiko,Nagoshi Narihito,Fujita Nobuyuki,Nakamura Masaya,Matsumoto Morio,Watanabe Kota 대한척추외과학회 2022 Asian Spine Journal Vol.16 No.3

Study Design: This is a retrospective study.Purpose: This study aims to evaluate the risk factor associated with pseudoarthrosis after placement of lateral interbody fusion (LIF) cages for adult spinal deformity (ASD) treatment. Overview of Literature: LIF technique is widely used for ASD correction. Furthermore, pseudoarthrosis is a major complication of fusion surgery required for revision surgery.Methods: This study included 42 patients with ASD (two men and 40 women; 112 segments; mean, 68.5±8.4 years; and mean follow-up, 31.6±17.0 months) who underwent LIF and posterior correction surgery. The concave slot of the LIF cage was filled with an autologous iliac crest bone graft (IBG), and the convex slot with a porous hydroxyapatite/collagen (HAp/Col) composite was soaked with bone marrow aspirate. Endplate injury, the gap between vertebral endplate and cage in the coronal or sagittal plane, and fusion status were evaluated using computed tomography multiplanar reconstruction at 12 months after surgery. Moreover, the associated risk factors for pseudoarthrosis were analyzed.Results: Fusion at LIF segments were observed in 71.4% segments at 12 months after surgery. Fusion on the concave slot (autologous IBG side), convex slot (porous HAp/Col composite side), and both concave and convex slots were observed in 66.1%, 37.5%, and 36.6% of patients, respectively. Moreover, pseudoarthrosis was observed in 28.6% at 12 months after surgery. Consequently, logistic regression analysis of the fusion at the LIF segment revealed that the gap between the LIF cage and endplate in the coronal plane (p=0.030; odds ratio, 0.183; 95% confidence interval, 0.030–0.183) was significantly associated with pseudoarthrosis at the LIF segments.Conclusions: ASD surgery fusion rate using LIF cages was 71.4% at 12 months after surgery. The fusion rate was higher on the concave slot filled with autologous IBG than on the convex slot filled with a porous HAp/Col composite. The gap in the coronal plane was a risk factor for pseudoarthrosis at the LIF segment.

Percutaneous Transpedicular Interbody Fusion Technique in Percutaneous Pedicle Screw Stabilization for Pseudoarthrosis Following Pyogenic Spondylitis

Ko Ikuta,Keigo Masuda,Yutaka Yonekura,Takahiro Kitamura,Hideyuki Senba,Satoshi Shidahara 대한척추외과학회 2016 Asian Spine Journal Vol.10 No.2

This report introduces a percutaneous transpedicular interbody fusion (PTPIF) technique in posterior stabilization using percutaneous pedicle screws (PPSs). An 81-year-old man presented with pseudoarthrosis following pyogenic spondylitis 15 months before. Although no relapse of infection was found, he complained of obstinate low back pain and mild neurological symptoms. Radiological evaluations showed a pseudoarthrosis following pyogenic spondylitis at T11–12. Posterior stabilization using PPSs from Th9 to L2 and concomitant PTPIF using autologous iliac bone graft at T11–12 were performed. Low back pain and neurological symptoms were immediately improved after surgery. A solid interbody fusion at T11–12 was completed 9 months after surgery. The patient had no restriction of daily activity and could play golf at one year after surgery. PTPIF might be a useful option for perform segmental fusion in posterior stabilization using PPSs.

One-Bone Forearm Procedure for Acquired Pseudoarthrosis of the Ulna Combined with Radial Head Dislocation in a Child: A Case with 20 Years Follow-Up

한수봉,최윤락,강호정,형지호 연세대학교의과대학 2011 Yonsei medical journal Vol.52 No.1

This report describes a 6 year-old boy who was treated with one-bone forearm procedure for acquired pseudoarthrosis of the ulna combined with radial head dislocation after radical ulna debridement for osteomyelitis. At more than 20 years of follow-up, the patient had a nearly full range of elbow movements with a few additional surgical procedures. Pronation and supination was restricted by 45°, but the patient had near-normal elbow and hand functions without the restriction of any daily living activity. This case shows that one-bone forearm formation is a reasonable option for forearm stability in longstanding pseudoarthrosis of the ulna with radial head dislocation in a child.

Ilizarov 골 유합술로 치료한 선천성 경골 가관절증의 중기 추시 결과

이기석(Ki Seok Lee),이상민(Sang Min Lee),조태준(Tae-Joon Cho),최인호(In Ho Choi),유원준(Won Joon Yoo),정진엽(Chin Youb Chung) 대한정형외과학회 2006 대한정형외과학회지 Vol.41 No.5

목적: 선천성 경골 가관절증 환아에서 Ilizarov 술식을 중심으로 한 치료의 유용성을 파악하고자 하였다. 대상 및 방법: Ilizarov 술식을 이용하여 골 유합숨을 시행받고, 3년 이상의 추시가 가능했던 22명의 선천성 경골 가관절증 환아의 치료 결과를 임상 및 방사선학적으로 평가하였다. 결과: 22명의 선천성 경골 가관절증 환아에서 평균 나이 4.6세에 Ilizarov 방법으로 골 유합술이 시도하여 100%의 골 유합을 얻었고, 12명에서 발생한 20예의 재골절에서도 100%의 골 유합을 얻었다. 42예의 Ilizarov 골 유합술 중 27예에서는 경골 연장술을, 23예에서는 내측 경골 나사못 골단판 유합술을, 17예에서는 원위 경비골 유합술을 함께 시행하였다. 평균 8.1년의 추시에서 하지 부동은 평균 1.6 cm였고, 경골 간부의 전방 각형성은 평균 6.3°, 외반 각형성은 평균 7.3°였다. 족근 관절 정렬 상태는 평균 외반 1.9°였고, 족근 관절 운동범위는 족배 굴곡 평균 21°, 족저 굴곡 평균 33°였다. 결론: Ilizarov 술식은 하지 연장술, 원위 및 근위 경골 골단판 내측 부분 유합술, 원위 경비골 유합술 등을 적절히 병합 시행하면 선천성 경골 가관절증 환아에서 골 유합뿐 아니라 기능적인 하지를 얻을 수 있는 유용한 방법이다. Purpose: This study evaluated the efficacy of the Ilizarov technique for the treatment of patients with congenital pseudoarthrosis of the tibia (CPT). Material and Methods: Twenty-two patients with CPT, who underwent osteosynthesis using the Ilizarov technique and were followed-up for more than 3 years, were enrolled in this study. The clinical and radiological data were reviewed to evaluate the outcomes of the Ilizarov technique. Results: The initial osteosynthesis was carried out successfully with the Ilizarov method at average age of 4.6 years. Twenty refractures occurred in 12 patients, who were also treated successfully using the Ilizarov method. Tibial lengthening (27 cases), medial tibial hemiepiphysiodesis (23 cases), distal tibiofibular synostosis (17 cases) were combined with a total of 42 Ilizarov osteosyntheses. After an average 8.1 years follow-up, the mean limb length discrepancy was 1.6 cm, and average anterior apex and valgus angulation of the tibial shaft were 6.3° and 7.3°, respectively. The mean ankle alignment was valgus 1.9, and the mean range of motion of the ankle joint was 21° dorsiflexion and 33° plantar flexion. Conclusion: The Ilizarov technique combined with tibial lengthening, distal tibiofibular synostosis and/or medial tibial hemiepiphysiodesis is an effective procedure that can achieve bony union as well as a functional limb.

Management of Andersson Lesion in Ankylosing Spondylitis Using the Posterior-Only Approach: A Case Series of 18 Patients

Ismail Shaik,Shekhar Yeshwant Bhojraj,Gautam Prasad,Premik Bhupendra Nagad,Priyank Mangaldas Patel,Aaditya Dattatreya Kashikar,Nishant Kumar 대한척추외과학회 2018 Asian Spine Journal Vol.12 No.6

Study Design: This retrospective study was conducted including 18 patients who underwent posterior-only stabilization and fusion procedure for pseudoarthrosis in the ankylosed spine from October 2007 to May 2015. Purpose: This study aimed to describe the treatment outcomes in 18 patients with Andersson lesion (AL) who were managed using the posterior-only approach. Literature Review: AL is an unstable, localized, vertebral, or discovertebral lesion of the spine. It is observed in patients with ankylosing spondylitis. The exact etiology of this disorder remains unclear, and the treatment guidelines are not clearly described. Methods: We analyzed 18 patients with AL who were treated with posterior long segment spinal fusion without any anterior interbody grafting or posterior osteotomy. Pre- and postoperative radiography, computed tomography, and recent follow-up images were examined. The pre- and postoperative Visual Analog Scale score and the Oswestry Disability Index score were evaluated for all patients. Whiteclouds’ outcome analysis criteria were applied at the follow-up. Moreover, at study completion, patient feedback was collected; all the patients were asked to provide their opinion regarding the surgery and were asked whether they would recommend this procedure to other patients and them self undergo the same procedure again if required. Results: The most common site was the thoracolumbar junction. The symptom duration ranged from 1 month to 10 years preoperatively. Most patients experienced fusion by the end of 1 year, and the fusion mass could be observed as early as 4 months. Pseudoarthrosis void of up to 2.5 cm was noted to be healed in subsequent imaging. In addition, clinically, the patients reported good symptomatic relief. No patient required revision surgery. Whiteclouds’ outcome analysis score at the latest follow-up revealed goodto- excellent outcomes in all patients. Conclusions: ALs can be treated using the posterior-only approach with long segment fixation and posterior spinal fusion. This is a safe, simple, and quick procedure that prevents the morbidity of anterior surgery.

Circumferential Fusion through All-Posterior Approach in Andersson Lesion

Sreekanth Reddy Rajoli,Rishi Mugesh Kanna,Siddharth N. Aiyer,Ajoy Prasad Shetty,Shanmuganathan Rajasekaran 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.3

Study Design: Retrospective case series. Purpose: To assess safety and efficacy of single stage, posterior stabilisation and anterior cage reconstruction through the transforaminal or lateral extra-cavitary route for Andersson lesions. Overview of Literature: Pseudoarthrosis in ankylosing spondylitis (Andersson lesion, AL) can cause progressive kyphosis and neurological deficit. Management involves early recognition and surgical stabilisation in patients with instability. However, the need and safety of anterior reconstruction of the vertebral body defect remains unclear. Methods: Twenty consecutive patients with AL whom presented with instability back pain and or neurological deficit were managed by single stage posterior approach with long segment pedicle screw fixation and anterior vertebral reconstruction. Radiological evaluation included- the regional kyphotic angle, measurement of anterior defect in computed tomography (CT) scan and the spinal cord status in magnetic resonance imaging. Radiological outcomes were assessed for fusion and kyphosis correction. Functional outcomes were assessed with visual analogue scale (VAS), ankylosing spondylitis quality of life (ASQoL) and Oswestry disability index (ODI). Results: The mean age of the patients was 50.1 years (male, 18; female, 2). The levels affected include thoracolumbar (n=12), lower thoracic (n=5) and lumbar (n=3) regions. The mean level of fixation was 6.2±2.4 vertebrae. The mean anterior column defect was 1.6±0.6 cm. The mean surgical duration, blood loss and hospital stay were 112 minutes, 452 mL and 6.2 days, respectively. The mean followup was 2.1 years. At final follow up, VAS for back pain improved from 8.2 to 2.4 while ODI improved from 62.7 to 18.5 (p <0.05) and ASQoL improved from 14.3±2.08 to 7.90±1.48 (p <0.05). All patients had achieved radiological union at a mean 7.2±4.6 months. The mean regional kyphotic angle was 27° preoperatively, 16.7° postoperatively and 18.1° at the final follow-up. Conclusions: Posterior stabilisation and anterior reconstruction with cage through an all-posterior approach is safe and can achieve good results in Andersson lesions.