The spine journal : official journal of the North American Spine Society
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The excellent clinical results of five US Federal Drug Administration (FDA) trials approved for cervical total disc replacement (TDR) (Prestige [Medtronic Sofamor Danek, Memphis, TN, USA], Bryan [Medtronic Sofamor Danek], ProDisc-C [Synthes, West Chester, PA, USA], Kineflex|C [SpinalMotion, Mountain View, CA, USA], and Mobi-C [LDR Spine, Austin, TX, USA]) have recently been published. In these prospective randomized studies, superiority or equivalency of TDR was claimed, citing an 8.7% (23/265), 9.5% (21/221), 8.5% (9/106), 12.2% (14/115), and 6.2% (5/81) (mean = 9.02%) rate of additional related cervical surgical procedures within 2 years in control anterior cervical discectomy and fusion (ACDF) patients, respectively, compared with 1.8% (5/276), 5.8% (14/242), 1.9% (2/103), 11% (15/136), and 1.2% (2/164) (mean = 4.34%) in patients receiving the cervical TDR. The rate of reoperation within 2 years after ACDF seems unusually high. ⋯ The present study identifies a 2.1% rate of repeat surgery within 2 years of a single-level ACDF performed during routine clinical practice, which is lower than that reported in the control arm of the Prestige, ProDisc-C, Bryan, Kineflex|C, and Mobi-C FDA trials (mean=9%). Even with longer follow-up including multilevel cases, our reoperation rate (7.6%) compared favorably with the IDE rates. This discrepancy may reflect different thresholds for reoperation in the control arm of a device IDE study compared with routine clinical practice. Additionally, patients enrolled in the single-level-only IDE trial may have received multilevel procedures outside of the study. This factor could result in a higher rate of subsequent surgeries at adjacent levels not addressed at the index procedure. These data suggest that we need to better understand factors driving treatment and, in particular, decisions to reoperate both in and outside of a device trial.
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Sensory and/or motor function sparing, including the S4-S5 spinal cord segment, is central to classifying neurologic impairment after spinal cord injury (SCI) using the American Spinal Injury Association Impairment Scale (AIS) grades within the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Within the ISNCSCI protocol, which is essential for both clinical and research purposes, assessing sacral sparing requires an anorectal and S4-S5 examination. However, in situations where these data are incomplete, the relationships between anorectal/S4-S5 examinations and functional preservation at more rostral sacral segments may be useful. ⋯ There are close relationships between functional sparing at different sacral segments. These relationships can be used to estimate AIS grades when complete information about the anorectal and S4-S5 examination is not available. The accuracy of the classification remains stable over time, while the increased variability in lower levels of SCI, that is, lumbar injuries, emphasizes the importance of careful sacral examinations. The highly reliable predictive values of S1-S3 segments can complement conclusions from anorectal examinations if the latter are considered to be confounded or incomplete.
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Multifidus cross-sectional area was often measured in chronic low back pain (LBP) patients to estimate the muscle activity for spinal stability. However, such estimation may be inadequate as the contribution of muscle elasticity in muscle activity is ignored. In vivo quantitative data on multifidus elasticity is therefore important for the study of muscle contractile function in response to motor control for spinal stability in chronic LBP patients. ⋯ Different, changing patterns of elasticity and cross-sectional area were identified in the multifidus in relation to posture. Increased stiffness of multifidus in response to the physiologic range of static loads and smaller cross-sectional area was characterized in the chronic LBP condition for spinal stability. Ultrasound elastography offers in vivo assessment of muscle contractile function of deep trunk muscles, which benefits the future investigation of the neuromuscular regulating mechanism in LBP. It can also be applied to refine the palpatory skill for the physical assessment in sports training and physical therapy.
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Minimal access surgery is becoming more popular for spinal fusion because of a lower theoretical risk of complications and shorter postoperative recovery period, compared with the traditional open approach. The lateral approach uses retroperitoneal transpsoas access to the vertebra, obviating the need for an approach surgeon and minimizing muscular disruption, thus allowing a quicker recovery. Initial reports of the lateral transpsoas procedure described few complications. However, a number of complications have subsequently been documented. To our knowledge, there has not been a description of an incisional hernia after this approach. ⋯ Postoperative incisional hernia after extreme lateral interbody fusion is a complication that has not been previously described in the literature but is one that spine surgeons must recognize. This case may prompt surgeons to use a more posterior approach to avoid this complication. Additionally, direct repair of the transversalis fascia is critical to avoiding this complication.