The spine journal : official journal of the North American Spine Society
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Most surgeons have thought that posterior decompression is necessary to treat isthmic spondylolisthesis with leg pain. However, the surgical procedure not only requires wide muscle dissection but can also lead to spinal instability. The authors' treatment concept for isthmic spondylolisthesis is one-stage anterior reduction and posterior stabilization with minimally invasive surgical procedure without touching the spinal thecal sac and nerve. ⋯ Mini-ALIF followed by percutaneous PF is an efficacious alternative for low-grade isthmic spondylolisthesis, and posterior decompression is not necessary to relieve leg symptoms. This minimally invasive combined procedure offers many advantages, such as preservation of posterior arch, no nerve retraction, less blood loss, excellent cosmetic results, high fusion rate and early discharge.
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Multicenter Study Clinical Trial
The Lumbar I/F Cage for posterior lumbar interbody fusion with the variable screw placement system: 10-year results of a Food and Drug Administration clinical trial.
The Lumbar I/F Cage is a carbon fiber reinforced polymer (CFRP) device designed to separate the mechanical and device functions of interbody fusion. A Investigational Device Exemption (IDE) clinical study of the CFRP cage was conducted during an enrollment period from 1991 to 1993. Based on the 2-year results of this study, the cage was approved by the US Food and Drug Administration (FDA) in February 1999. Since then, the Lumbar I/F Cage device has become widely used in the United States. ⋯ The high rate of clinical success, fusion success, and patient satisfaction at 24 months was maintained at 10-year follow-up. Adjacent segment degeneration was common but was usually not clinically significant.
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Total disc arthroplasty serves as the next frontier in the surgical management of intervertebral discogenic pathology. ⋯ The implementation of dynamic spinal stabilization systems for fusionless correction of spinal deformity, dynamic posterior stabilization and total disc arthroplasty necessitates improved understanding with regard to spinal kinematics, patterns and mechanisms of histologic osseointegration and the neurohistopathologic response to particulate wear debris. Collectively, the current studies provide a methodologic basis to comprehensively evaluate these three areas.
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There are both absolute and relative indications for the removal of pedicle screw fixation in the lumbar spine. Whatever the reasons are, removal of this hardware has required a surgical dissection that has been generally as extensive as the one used for their initial placement. These dissections are always disabling in the short term. In fact, the magnitude of this disabling pain can be significant enough so as to effectively eliminate screw removal as a logical treatment option for many conditions where indications for removal are only relative. Percutaneous pedicle screw fixation has served to amplify the stakes associated with this dilemma. In fact, this new technique makes the need for a less invasive method of pedicle screw removal greater now than ever. ⋯ Unlike most other minimal access surgical procedures, the learning curve for this procedure appears to be relatively flat. Removal of pedicle screw fixation in the manner described proved to be simple and straightforward. The benefits are dramatic and immediate. It is possible to complete the procedure within minutes, and the pain produced is best described as inconsequential. This minimally invasive technique radically alters both the intraoperative and postoperative courses for those who face pedicle screw removal. The disadvantages associated with the standard open approach are reduced to the production of mild short-term discomfort and an exposure to the potential risks of brief anesthesia and the possibility of a surgical infection. Considering that hospital stay should be limited to I day or less and that surgical times are less than I hour, minimally invasive removal or revision of hardware should reduce overall costs significantly.
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Malignant spinal lesions may require surgical excision and segmental stabilization. The decision to perform a concomitant fusion procedure is influenced in part by the need for adjunctive chemotherapy as well as the patient's anticipated survival. Although some evidence exists that suggests that chemotherapy may inhibit bony healing, no information exists regarding the effect of chemotherapy on spinal fusion healing. ⋯ No significant differences in wound complications were noted with doxorubicin administration. A single dose of doxorubicin administered intravenously at the time of surgery appears to play a significant inhibitory role in the process of spinal fusion. If similar effects occur in humans, these data suggest that doxorubicin may be harmful to bone healing in a spine fusion if given during the perioperative period. Further investigation will be necessary to determine the effect of time to aid at determining whether doxorubicin administered several weeks pre- or postoperatively results in improved fusion rate, and whether bone morphogenetic proteins can overcome these inhibitory effects.