Revision surgery after interbody fusion with rhBMP-2: a cautionary tale for spine surgeons

2013 ◽  
Vol 18 (6) ◽  
pp. 582-587 ◽  
Author(s):  
Shaun D. Rodgers ◽  
Bryan J. Marascalchi ◽  
Bartosz T. Grobelny ◽  
Michael L. Smith ◽  
Uzma Samadani
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Vascular Injury ◽  
Interbody Fusion ◽  
Iliac Vein ◽  
Bone Morphogenetic Protein 2 ◽  
Retroperitoneal Approach ◽  
Low Back ◽  
Lumbar Interbody Fusion ◽  
Interbody Cage

Recombinant human bone morphogenetic protein–2 (rhBMP-2) promotes the induction of bone growth and is widely used in spine surgery to enhance arthrodesis. Recombinant human BMP-2 has been associated with a variety of complications including ectopic bone formation, adjacent-level fusion, local bone resorption, osteolysis, and radiculitis. Some of the complications associated with rhBMP-2 may be the result of rhBMP-2 induction of the inflammatory host response. In this paper the authors report on a patient with prior transforaminal lumbar interbody fusion (TLIF) using an interbody cage packed with rhBMP-2, in which rhBMP-2 possibly contributed to vascular injury during an attempted anterior lumbar interbody fusion. This 63-year-old man presented with a 1-year history of worsening refractory low-back pain and radiculopathy caused by a Grade 1 spondylolisthesis at L4–5. He underwent an uncomplicated L4–5 TLIF using an rhBMP-2–packed interbody cage. Postoperatively, he experienced marginal improvement of his symptoms. Within the next year and a half the patient returned with unremitting low-back pain and neurogenic claudication that failed to respond to conservative measures. Radiological imaging of the patient revealed screw loosening and pseudarthrosis. He underwent an anterior retroperitoneal approach with a plan for removal of the previous cage, complete discectomy, and placement of a femoral ring. During the retroperitoneal approach the iliac vein was adhered with scarring and fibrosis to the underlying previously operated L4–5 interbody space. During mobilization the left iliac vein was torn, resulting in significant blood loss and cardiac arrest requiring chest compression, defibrillator shocks, and blood transfusion. The patient was stabilized, the operation was terminated, and he was transferred to the intensive care unit. He recovered over the next several days and was discharged at his neurological baseline. The authors propose that the rhBMP-2–induced host inflammatory response partially contributed to vessel fibrosis and scarring, resulting in the life-threatening vascular injury during the reoperation. Spine surgeons should be aware of this potential inflammatory fibrosis in addition to other reported complications related to rhBMP-2.

Surgical treatment of adult degenerative spondylolisthesis by instrumented transforaminal lumbar interbody fusion in the Han nationality

2009 ◽  
Vol 10 (5) ◽  
pp. 496-499 ◽  
Author(s):  
Hao Xu ◽  
Hao Tang ◽  
Zhonghai Li
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Interbody Fusion ◽  
Degenerative Spondylolisthesis ◽  
Transforaminal Lumbar Interbody Fusion ◽  
Low Back ◽  
Lumbar Interbody Fusion ◽  
Peek Cage ◽  
Han Nationality

Object The transforaminal lumbar interbody fusion (TLIF) procedure was developed to provide the surgeon with a fusion procedure that may reduce many of the risks and limitations associated with posterior lumbar interbody fusion, yet produce similar stability in the spine. There are few large series with long-term follow-up data regarding instrumented TLIF and placement of 1 diagonal polyetheretherketone (PEEK) cage. The authors performed a prospective study to evaluate the outcome and safety of instrumented TLIF with 1 diagonal PEEK cage for degenerative spondylolisthesis in the Han nationality in China. Methods Between May 2001 and April 2006, 60 patients (35 men and 25 women; mean age 55.5 years, range 45–70 years) with symptomatic degenerative spondylolisthesis underwent the TLIF procedure with 1 diagonal PEEK cage and additional pedicle screw internal fixation at the authors' institution. The inclusion criteria involved degenerative spondylolisthesis (Grades I and II) in patients with chronic low-back pain with or without leg pain. Results One patient had a postoperative temporary motor and sensory deficit of the adjacent nerve root. Reoperation was required in 1 patient because of pedicle screw migration. One patient developed a pseudarthrosis and had increasing complaints of low-back pain 1 year postoperatively and underwent a subsequent revision surgery. Two patients had nerve root symptomatic compression resulting from cage migration and insufficient decompression after surgery, and they underwent revision. Two patients had a dural tear that required fibrin glue application during surgery. No implant fracture or subsidence occurred in any patient. Clinically, the pain index and Oswestry Disability Index (ODI) score improved significantly from before surgery to the 2-year follow-up. In the TLIF group, the pain index improved from 69 to 25 (p < 0.001). The postoperative ODI showed a significant postoperative reduction of disability during the whole period of follow-up (p < 0.001). The preoperative mean ODI score was 32.3 (16–80), and postoperative 13.1 (0–28). Disc space height and foraminal height were restored by the surgery and maintained at the latest follow-up time. Conclusions In the authors' experience, instrumented TLIF with 1 diagonal PEEK cage can be a surgical option for treatment of degenerative spondylolisthesis in the Han nationality in China.

Intramuscular pressure of the multifidus muscle and low-back pain after posterior lumbar interbody fusion: comparison of mini-open and conventional approaches

2013 ◽  
Vol 19 (6) ◽  
pp. 651-657 ◽  
Author(s):  
Yoshihiro Mukai ◽  
Shota Takenaka ◽  
Noboru Hosono ◽  
Toshitada Miwa ◽  
Takeshi Fuji
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Interbody Fusion ◽  
Posterior Lumbar Interbody Fusion ◽  
Low Back ◽  
Lumbar Interbody Fusion ◽  
Intramuscular Pressure ◽  
Multifidus Muscle ◽  
Screw Insertion ◽  
Mini Open

Object This randomized study was designed to elucidate the time course of the perioperative development of intramuscular multifidus muscle pressure after posterior lumbar interbody fusion (PLIF) and to investigate whether the route of pedicle screw insertion affects this pressure and resultant low-back pain. Although several studies have focused on intramuscular pressure associated with posterior lumbar surgery, those studies examined intramuscular pressure generated by the muscle retractors during surgery. No study has investigated the intramuscular pressure after PLIF. Methods Forty patients with L4–5 degenerative spondylolisthesis were randomly assigned to undergo either the mini-open PLIF procedure with pedicle screw insertion between the multifidus and longissimus muscles (n = 20) or the conventional PLIF procedure via a midline approach only (n = 20). Intramuscular pressure was measured 5 times (at 30 minutes and at 6, 12, 24, and 48 hours after surgery) with an intraoperatively installed sensor. Concurrently, the FACES Pain Rating Scale score for low-back pain and the total dose of postoperative analgesics were recorded. Results With the patients in the supine position, for both groups the mean pressure values were consistently 40–50 mm Hg, which exceeded the critical capillary pressure of the muscle. With the patients in the lateral decubitus position, the pressure decreased over time (from 14 to 9 mm Hg in the mini-open group and from 20 to 10 mm Hg in the conventional group). Among patients in the mini-open group, the pressure was lower, but the difference was not statistically significant. Postoperative pain and postoperative analgesic dosages were also lower . Conclusions To the authors' knowledge, this is the first study to evaluate postoperative intramuscular pressure after PLIF. Although the results did not demonstrate a significant difference in the intramuscular pressure between the 2 types of PLIF, mini-open PLIF was associated with less pain after surgery. Clinical trial registration no.: UMIN000010069 (www.umin.ac.jp/ctr/index.htm).

Vertebral osteolytic defect due to cellulose particles derived from gauze fibers after posterior lumbar interbody fusion

2014 ◽  
Vol 21 (6) ◽  
pp. 877-881 ◽  
Author(s):  
Shota Takenaka ◽  
Yoshihiro Mukai ◽  
Noboru Hosono ◽  
Kosuke Tateishi ◽  
Takeshi Fuji
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Interbody Fusion ◽  
Histopathological Examination ◽  
Lumbar Fusion ◽  
Posterior Lumbar Interbody Fusion ◽  
Low Back ◽  
Lumbar Interbody Fusion ◽  
Body Type ◽  
Initial Surgery

Vertebral cystic lesions may be observed in pseudarthroses after lumbar fusion surgery. The authors report a rare case of pseudarthrosis after spinal fusion, accompanied by an expanding vertebral osteolytic defect induced by cellulose particles. A male patient originally presented at the age of 69 years with leg and low-back pain caused by a lumbar isthmic spondylolisthesis. He underwent a posterior lumbar interbody fusion, and his neurological symptoms and pain resolved within a year but recurred 14 months after surgery. Radiological imaging demonstrated a cystic lesion on the inferior endplate of L-5 and the superior endplate of S-1, which rapidly enlarged into a vertebral osteolytic defect. The patient underwent revision surgery, and his low-back pain resolved. A histopathological examination demonstrated foreign body–type multinucleated giant cells, containing 10-μm particles, in the sample collected just below the defect. Micro–Fourier transform infrared spectroscopy revealed that the foreign particles were cellulosic, presumably originating from cotton gauze fibers that had contaminated the interbody cages used during the initial surgery. Vertebral osteolytic defects that occur after interbody fusion are generally presumed to be the result of infection. This case suggests that some instances of vertebral osteolytic defects may be aseptically induced by foreign particles. Hence, this possibility should be carefully considered in such cases, to help prevent contamination of the morselized bone used for autologous grafts by foreign materials, such as gauze fibers.

Full Percutaneous Lumbar Interbody Fusion: Technical Note

2017 ◽  
Vol 78 (06) ◽  
pp. 601-606 ◽  
Author(s):  
Mitsuto Taguchi ◽  
Shu Nakamura
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Pedicle Screw ◽  
Interbody Fusion ◽  
Screw Fixation ◽  
Pedicle Screw Fixation ◽  
Low Back ◽  
Lumbar Interbody Fusion ◽  
Less Invasive ◽  
Disk Degeneration

Introduction Although lumbar interbody fusion is effective for low back pain caused by severe disk degeneration, it is a highly invasive procedure. Less invasive procedures such as transforaminal lumbar interbody fusion (TLIF) and lumbar lateral interbody fusion have become available; however, there is still scope for improvement. We performed full percutaneous endoscopic lumbar interbody fusion (PELIF), a technique designed as a safe and less invasive percutaneous fusion. Method and Subjects Our technique is indicated for patients with chronic low back pain in whom conservative treatment was not effective, thinning of the intervertebral disk was prominent, and temporary pain relief was achieved with a disk block. In the operation, percutaneous endoscopic diskectomy was performed with a 7.5-mm sheath inserted through a small incision, and a cage was inserted percutaneously using an L-shaped retractor. Instead of pedicle screw fixation, hybrid facet screw fixation was performed. Low back pain was improved, and bone union was confirmed on radiography. This technique was used in six patients, and no surgery-related complications occurred. Discussion The L-shaped retractor used in this series can protect the exiting nerve by inserting it into the sheath, then removing the sheath and placing the rounded corner of the retractor on the lateral cranial side. This technique is safe with no other associated risks. Cages larger than the sheath can be inserted, and commercially available cages for TLIF are applicable. Hybrid facet screw fixation can overcome the problems associated with both conventional transfacet pedicle screw fixation and translaminar facet screw fixation by combining these two procedures. Conclusion PELIF is an easy, safe, and fully percutaneous technique with very low invasiveness that uses an L-shaped retractor and hybrid facet screw fixation. This procedure can be a treatment option for patients with severe low back pain related to disk degeneration.

scholarly journals Analysis of Spinopelvic Sagittal Balance and Persistent Low Back Pain (PLBP) for Degenerative Spondylolisthesis (DS) following Posterior Lumbar Interbody Fusion (PLIF)

2020 ◽  
Vol 2020 ◽  
pp. 1-7
Author(s):  
Shuangjun He ◽  
Yijian Zhang ◽  
Wei Ji ◽  
Hao Liu ◽  
Fan He ◽  
...  
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Clinical Outcomes ◽  
Sagittal Balance ◽  
Interbody Fusion ◽  
Degenerative Spondylolisthesis ◽  
Posterior Lumbar Interbody Fusion ◽  
Low Back ◽  
Lumbar Interbody Fusion ◽  
Spinopelvic Parameters

Objective. To investigate the change of spinopelvic sagittal balance and clinical outcomes after posterior lumbar interbody fusion (PLIF) in patients with degenerative spondylolisthesis (DS), especially the relationship between sagittal spinopelvic parameters and persistent low back pain (PLBP). Methods. 107 patients who were diagnosed with DS and underwent PLIF in our department were enrolled retrospectively in the present study. Sagittal spinopelvic parameters including lumbar lordosis (LL), segmental lordosis (SL), height of the disc (HOD), sacral slope (SS), pelvic incidence (PI), and pelvic tilt (PT) were recorded pre- and postoperatively. Sagittal balance and clinical outcomes were compared between patients with and without PLBP. Pearson correlation was used to analyze the change of sagittal balance parameters and clinical functions. Logistic regression analysis was performed to examine the risk factors of PLBP. Results. It showed significant improvements of SL, HOD, and PT postoperatively. Both the Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI) had significant improvement postoperatively. Change of PT and SL also differed observably between patients with and without PLBP. SL and PT were correlated with NRS and ODI, and insufficient restoration of PT was an independent factor for PLBP. Conclusion. The sagittal balance parameters and clinical outcomes can be improved markedly via PLIF for treating DS. Restoration of SL and PT was correlated with satisfactory outcomes, and adequate improvement of PT may have positive impact on reducing PLBP.

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