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Fusion of the Spine

by Wheeless' Textbook of Orthopaedics

  • Anterior Arthrodesis of the Subaxial Cervical Spine
  • AAOS - Bulletin: A minute of malpractice

Cage Fixation: (interbody fusion)
  • provides excellent stabilization in flexion and lateral bending, but poor stabilization in extension and rotation;
  • advantage: may offer fusion rates of over 90% and does not interfere with posterior musculature;
  • disadvantage is that a decompression is not possible (if the anterior approach is utilized);
  • complications may be higher when cage fixation is performed through a posterior approach;
  • specifically this approach may cause chronic radiculopathy due to epineural fibrosis caused by the added epidural manipulation which is required for this technique;
  • another complication associated with a posterior approach is retropulsion of the cage back into the spinal canal causing neurological deficit;

Pedicle Screw Fixation
  • pedicle screw fixation is generally felt to enhance spinal fusion by providing rigid fixation of spinal vertebrae;
  • in the prospective study by France et al 1999, the authors did not find that pedicle screw instrumentation benefited patients undergoing spinal fusion, except in patients with degenerative spondylolisthesis;
  • patients with degenerative disc dz had 63% good to excellent results w/ instrumentation vs 73% w/o instrumentation;
  • in those w/ degenerative spondylolisthesis, good to excellent results were found in 80% of patients w/instrumentation vs 40% w/o instrumentation;

S1 dorsal screw placement
  • in the anatomic study by S. Stanescu and RA Yeasting et al (Orthopedics March 2000, Vol 23, No 3 p 245), the authors determined the safe zone for S1 screw placement;
  • using a starting point located inferlateral to the S1 superior facet, the authors recommend screw direction 30 to 40 deg lateral to avoid comprimising the lumbrosacral trunk and SI joint;
  • insertion medial to this direction, might injure the L4 or L5 nerve roots;
  • complications: nerve root irriation may be more common with medially placed screws;
  • Castro et al (Spine 1996; 21: 1320-1324), performed a study of 30 patients with 131 screws placed under flouroscopic control; CT images showed cortical penetration in 40% and medial wall penetration in 29%; deviation on CT of more than 6mm indicated a high risk of nerve root injury;;

  • risk factors include: previous surgery, increased number of fusion levels;
  • exam findings: worsening of preoperative symptoms; localized lumbar tenderness;
  • diagnostic studies: radiographs: look for hardware failure; flexion / extension radiographs (look for abnormal translation); 4 mm of translation or more than 10 deg of angular motion between adjacent end plates (comparing flexion and extension views); upto 3 mm of motion can be a normal finding;
  • bone scan: increased uptake has little predictive value until one year after surgery; AP tomograms: best radiographic test for pseudoarthrosis;
  • surgery: allows best assessment of non-union;

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