The Safety Profile of Intentional or Iatrogenic Sacrifice of the Artery of Adamkiewciz and Its Vicinity’s Spinal Segmental Arteries: A Systematic Review

Study Design: Systematic review. Objectives: There is paucity of consensus on whether (1) the artery of Adamkiewicz (AoA) and (2) the number of contiguous segmental spinal arteries (SSAs) that can be safely ligated without causing spinal cord ischemia. The objective of this review is to determine the risk of motor neurological deficits from iatrogenic sacrifice of the (1) AoA and (2) its vicinity’s SSAs. Methods: Systematic review of the spine and vascular surgery was carried out in accordance to PRISMA guidelines. Outcomes in terms of risk of postoperative motor neurological deficit with occlusion of the AoA, bilateral contiguous SSAs, or unilateral contiguous SSAs were analyzed. Results: Ten articles, all retrospective case series, were included. Three studies (total N = 50) demonstrated a postoperative neurological deficit risk of 4.0% when the AoA is occluded. When 1 to 6 pairs of SSAs (without knowledge of AoA location) were ligated, the postoperative neurological deficit risk was 0.6%, as compared with 5.4% when more than 6 bilateral pairs of SSAs were ligated (relative risk [RR] = 0.105, 95% CI 0.013-0.841, P =.0337). For unilateral ligation of SSAs of two to nine levels, the risk of postoperative neurological deficit does not exceed 1.3%. Conclusion: The current best evidence indicates that (1) occlusion of the AoA and (2) occlusion of up to 6 pairs of SSAs is associated with a low risk of postoperative neurological deficit. This limited number of low quality studies restrict the ability to draw definitive conclusions. Ligation of AoA and SSAs should only be undertaken when absolutely required to mitigate the small but devastating risk of paralysis

Cyanoacrylate Dermal Closure in Spine Surgery: Systematic Review and Pooled Analysis

Study Design: Systematic review. Objectives: Cyanoacrylate glue closure has been utilized for dermal closure in surgical incisions. Its safety and efficacy in spine surgery are not established. The authors perform a systematic review to determine the rate of surgical site infection (SSI), wound dehiscence, and wound erythema with cyanoacrylate dermal closure in spine surgery. Methods: A systematic review adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed utilizing the PubMed/MEDLINE, EMBASE, and Cochrane databases on patients undergoing spine surgery with cyanoacrylate dermal closure. Pooled analysis was performed with stratification of patients according to spinal level and the presence/absence of instrumentation. Risk-of-bias and methodological quality was appraised using 17 prespecified criteria. Results: Five articles (1 retrospective cohort study, 4 cases series) with a total of 1282 patients were included. A total of 967 patients, all diagnosed with degenerative spine disease, were suitable for pooled analysis. In 290 patients who underwent anterior cervical discectomy and fusion, and in 23 patients with posterior cervical decompression (without instrumentation), there was 0% rate of SSI, wound dehiscence, and erythema. In 489 patients who underwent lumbar microdiscectomy, there was 0.41% rate of SSI, 0.20% rate of wound dehiscence, and 0.20% rate of wound erythema. In 165 lumbar laminectomy patients, there was a 1.82% rate of SSI, 0.61% rate of wound dehiscence, and 0% rate of wound erythema. Conclusion: Cyanoacrylate dermal closure for the aforementioned procedures is associated with low rates of wound complications (SSI, dehiscence, and erythema). Further studies should be performed, especially in nondegenerative surgery, instrumented thoracic and lumbar spine surgery

Anterior versus posterior approach in traumatic thoracolumbar burst fractures deemed for surgical management: Systematic review and meta-analysis

Uncertainties remain regarding the optimal surgical approach in the treatment of traumatic thoracolumbar burst fractures. We aim to compare the surgical, radiological and functional outcomes in anterior versus posterior approaches in patients with traumatic thoracolumbar burst fractures deemed for surgical management. A systematic review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Qualitative analysis and where suitable, meta-analysis were performed to compute pooled estimates of the differences between anterior and posterior approaches. A total of six studies (three observational, one prospective non-randomized trial, two randomized controlled trials) were included. There were no cases of postoperative neurological decline. Meta-analysis demonstrates a longer duration (Mean Difference (MD) + 81.68, 95% CI 39.20 to 123.16, p < 0.001) and increased estimated blood loss (MD + 426.27, 95% CI 119.84 to 732.70, p = 0.006) for the anterior approach. No difference between approaches was found regarding length of hospital stay, late postoperative kyphotic angle, construct failure rate, instrumentation revision rate, rate of return to work, and total hospital charges. Limitations include the small number of, and heterogeneity across studies. Given the similarities in neurological, radiological and functional outcomes between the two approaches, the longer duration and estimated blood loss in the anterior approach should be a point of consideration when selecting the surgical approach. There is an urgent need for contemporary, high quality research in this area

Towards new treatment strategies for intervertebral disc degeneration : Pathophysiology, histological and biochemical changes in IVD degeneration

Approximately 70% to 80% of all people worldwide will experience low back at any moment in their life. Intervertebral disc degeneration is an important cause of chronic low back pain. In most cases chronic low back pain can be treated conservatively with physiotherapy and analgesia. However, in some cases conservative treatment is not sufficient and surgical treatment, spinal fusion or placement of an intervertebral disc prosthesis, is indicated. Unfortunately the outcome of these surgical interventions is rather disappointing and there is a substantial risk of devastating complications. In the past decade several new regenerative treatment strategies for intervertebral disc degeneration have been developed. These new strategies focus on restoring the biomechanical function of the degenerative disc instead of replacing or removing the intervertebral disc. For the further development of regenerative treatment strategies, thorough understanding of the pathophysiology of the degenerative process is essential. Therefore, the main aim of this thesis is to contribute to a better understanding of the pathophysiology of IVD degeneration. In this thesis we’ll describe new therapeutic targets, evaluate which animal model is most suitable to simulate human intervertebral degeneration and we investigate if it possible to prevent intervertebral disc degeneration by local injection of growth factors and enzyme inhibitors

Timing of thoracic and lumbar fracture fixation in spinal injuries: a systematic review of neurological and clinical outcome.

A systematic review of all available evidence on the timing of surgical fixation for thoracic and lumbar fractures with respect to clinical and neurological outcome was designed. The purpose of this review is to clarify some of the controversy about the timing of surgical fracture fixation in spinal trauma. Better neurological outcome, shorter hospital stay and fewer complications have been reported after early fracture fixation. But there are also studies showing no difference in neurological outcome when compared to late treatment. Mortality is another controversial point since a recent report of higher mortality in early treated patients. A systematic review of the literature was preformed. Ten articles were included. Early fracture fixation is associated with less complications, shorter hospital and ICU stay. The effect of early treatment on the neurological outcome remains unclear due to the contradictory results of the included studies. Early thoracic and lumbar fracture fixation results in improvement of clinical outcome, but the effect on neurological outcome remains controversial

Outcome of traumatic thoracolumbar spine fractures in elderly: A systematic review

Introduction: Adequate guidelines for treatment of people over 65 years, suffering traumatic thoracolumbar spine fractures without neurologic deficit, are currently lacking. Research question: The aim of this study was to systematically review the available literature regarding the outcome of conservative and surgical treatment of thoracolumbar spinal trauma in elderly patients. Material and methods: A systematic review according the PRISMA guidelines was performed. Pubmed, Web of Science, EMBASE and the Cochrane Central register were searched until June 2021. Risk of bias of the included studies was evaluated. Clinical and radiological results, as well as complications of conservative or surgical treatment were reviewed. Results: Six articles were included (one prospective randomized trial, two prospective and three retrospective cohort studies). In these studies conflicting results were observed with regard to pain, radiological results and complications following both conservative and surgical treatment strategies for thoracolumbar spine fractures in elderly. Discussion and conclusion: Treatment of thoracolumbar fractures in elderly should focus on early mobilization to reduce complications and hospital stay. This may improve functional outcome and prevent worsening of frailty in this vulnerable group of patients. To elucidate the optimal treatment for elderly patient with thoracolumbar fractures, future research should focus on patient specific treatment rather than the mere difference between outcome of surgical and conservative treatment

Effects of 8 years of growth hormone treatment on scoliosis in children with Prader-Willi syndrome

Objective Scoliosis is frequently seen in children with Prader–Willi syndrome (PWS). There is still concern that growth hormone (GH) treatment might increase the risk of onset or progression of scoliosis. Short-term data suggested no adverse effects of GH on scoliosis, but long-term effects of GH treatment on development of scoliosis in PWS are unknown. This study investigated the effects of 8 years of GH treatment on scoliosis in children with PWS. Design Open-label, prospective cohort study in 103 children with PWS receiving GH for 8 years was analyzed. Prevalence and severity of scoliosis were compared to a group of 23 age-matched GH-untreated children with PWS. Methods Spine X-rays and DEXA-scans were performed, and Cobb angel was measured by two independent observers. Results After 8 years of GH treatment, at median age of 10.8 years, prevalence of scoliosis was 77.7%. No difference in prevalence or severity of scoliosis was found between GH-treated and age-matched untreated children with PWS (P = 0.409 and P = 0.709, respectively). Height SDS and trunkLBM were significantly higher in GH-treated children. Higher bone mineral density of the lumbar spine was found in children without scoliosis after 8 years of GH. Bone mineral apparent density of lumbar spine (BMADLS) SDS was associated with lower Cobb angle (r = −0.270, P = 0.008). Conclusions Eight years of GH treatment has no adverse effects on the prevalence and severity of scoliosis in children with PWS until 11 years of age. As BMADLS SDS is inversely associated with Cobb angle, it is pivotal to optimize the BMD status in children with PWS

Does combined anterior-posterior approach improve outcomes compared with posterioronly approach in traumatic thoracolumbar burst fractures? A systematic review

The aim of this systematic review was to evaluate the surgical, radiological, and functional outcomes of posterior-only versus combined anterior-posterior approaches in patients with traumatic thoracolumbar burst fractures. The ideal approach (anterior-only, posterior-only, or combined anterior-posterior) for the surgical management of thoracolumbar burst fracture remains controversial, with each approach having its advantages and disadvantages. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed (registration no., CRD42018115120). The authors reviewed comparative studies evaluating posterior-only approach compared with combined anterior-posterior approaches with respect to clinical, surgical, radiographic, and functional outcome measures. Five retrospective cohort studies were included. Postoperative neurological deterioration was not reported in either group. Operative time, estimated blood loss, and postoperative length of stay were increased among patients in the combined anterior-posterior group in one study and equivalent between groups in another study. No significant difference was observed between the two approaches with regards to long-term postoperative Cobb angle (mean difference,-0.2; 95% confidence interval,-5.2 to 4.8; p =0.936). Moreover, no significant difference in functional patient outcomes was observed in the 36-item Short-Form Health Survey, Visual Analog Scale, and return-to-work rates between the two groups. The available evidence does not indicate improved clinical, radiologic (including kyphotic deformity), and functional outcomes in the combined anterior-posterior and posterior-only approaches in the management of traumatic thoracolumbar burst fractures. Further studies are required to ascertain if a subset of patients will benefit from a combined anterior-posterior approach