Objective Facet joint injections (FJIs) and medial branch blocks (MBBs) are commonly used interventions for chronic spinal pain, but their comparative effectiveness remains unclear. This meta-analysis aimed to compare the pain relief, functional improvement, complications, and patient satisfaction associated with FJI and MBB.
Methods A systematic review and meta-analysis of randomized controlled trials and observational studies were conducted. Primary outcomes included pain relief (numerical rating scale) and functional improvement (Oswestry Disability Index [ODI]/Neck Disability Index). Secondary outcomes assessed adverse effects and patient satisfaction. The differences in characteristics between patients who were readmitted and those who were not were identified and analyzed using the Review Manager software.
Results FJI resulted in lower pain and ODI scores compared to MBB, but the differences were not statistically significant. However, patient satisfaction was significantly higher in the FJI group (odds ratio, 1.81; 95% confidence interval, 1.02–3.24; p=0.04). Additionally, FJI had fewer adverse effects than MBB.
Conclusion Both FJI and MBB are effective for chronic spinal pain, but FJI may be preferred for patients seeking immediate pain relief with fewer complications. Further high-quality studies are needed to refine treatment guidelines.
Objective We investigated the clinical efficacy of anabolic agents compared with bisphosphonates (BPs) for the incidence of new osteoporotic vertebral fracture (OVF) and fracture healing of OVF in the patients with OVF via meta-analyses of randomized controlled trials (RCTs).
Methods Electronic databases, including PubMed, Embase, and Cochrane Library were searched for published RCTs till December 2022. The RCTs that recruited participants with osteoporosis at high-/very high-risk of fracture (a history of osteoporotic vertebral or hip fracture) or fresh OVF were included in this study. We assessed the risk of bias on every included RCTs, estimated relative risk (RR) for the incidence of new OVF and fracture healing of OVF, and overall certainty of evidence. Meta-analyses were performed by Cochrane review manager (RevMan) ver. 5.3. Cochrane risk of bias 2.0 and GRADEpro/GDT were applied for evaluating methodological quality and overall certainty of evidence, respectively.
Results Five hundred eighteen studies were screened, and finally 6 eligible RCTs were included in the analysis. In the patients with prevalent OVF, anabolic agents significantly reduced the incidence of new OVF (teriparatide and romosozumab vs. alendronate and risedronate [RR, 0.57; 95% confidence interval, 0.45–0.71; p < 0.00001; high-certainty of evidence]; teriparatide vs. risedronate [RR, 0.50; 95% confidence interval, 0.37–0.68; p < 0.0001; high-certainty of evidence]). However, there was no evidence of teriparatide compared to alendronate in fracture healing of OVF (RR, 1.23; 95% confidence interval, 0.95–1.60; p = 0.12; low-certainty of evidence).
Conclusion In the patients with prevalent OVF, anabolic agents showed a significant superiority for preventing new OVF than BPs, with no significant evidence for promoting fracture healing of OVF. However, considering small number of RCTs in this study, additional studies with large-scale data are required to obtain more robust evidences.
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Objective Although several studies have reported successful fusion rates after oblique lumbar interbody fusion (OLIF) using allografts or dimerized bone matrix (DBM) instead of autografts, whether OLIF can achieve satisfactory solid fusion without the use of autografts remains unclear. This study investigated the real fusion rates after OLIF using allografts and DBM, which were evaluated using both dynamic radiographs and computed tomography scans.
Methods We enrolled 79 consecutive patients who underwent minimally invasive OLIF followed by percutaneous pedicle screw fixation. All patients were treated with OLIF between L2 and L5 and underwent radiographic and clinical follow-ups at 12, 18, and 24 months after surgery. Radiographic assessment of fusion was performed using the modified BrantigaSteffee-Fraser (mBSF) scale, which was categorized as follows: grades I (radiographic pseudoarthrosis), II (indeterminate fusion), and III (solid radiographic fusion). Other radiologic and clinical outcomes were evaluated using the following parameters: vertebral slippage distance, disc height, subsidence, Oswestry Disability Index (ODI), and visual analogue scale (VAS).
Results Clinical outcomes demonstrated significant improvements in the VAS scores for back pain, leg pain, and ODI after surgery. Subsidence was present in 34 cases (35.4%) at 12 months postoperatively, which increased to 47.9% and reached 50.0% at 1.5 years and 2 years after surgery, respectively. The solid fusion rate after OLIF was 32.3% at 1 year, increased to 58.3% at 1.5 years, and reached 72.9% at 2 years. Radiographic pseudoarthrosis was 24.0% at 1 year, which decreased to 6.3% at 1.5 years and 3.1% at 2 years.
Conclusion OLIF is a safe and effective surgical procedure for the treatment of degenerative lumbar diseases. The mBSF scale, which simultaneously evaluates both dynamic angles and bone bridge formation, offers great reliability for the radiological assessment of fusion. Moreover, OLIF using allografts and DBM, which is performed on one or 2 levels at L2–5, can achieve satisfactory fusion rates within 2 years after surgery.
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Methods We calculated bone cement volume (BCV); vertebral body volume (VBV); leaked intradiscal BCV; and spatial, symmetric, and even bone cement distribution (BCD) in and out of 222 vertebral bodies treated with 2 different PVPs using VBM and evaluated the incidence of subsequent vertebral compression fracture (SVCF). Statistical analyses were conducted to compare values between the 2 different PVPs.
Results Relative BCV, which is a potential risk factor for SVCF, was higher in the BTV group based on the data using VBM (0.22±0.03 vs. 0.29±0.03; p<0.001, t-test); however, the SVCF incidence between the 2 surgeries was not significantly different (UEV, 24.7%; BTV, 31%; p=0.046, chi-square test). Spatial, even, and symmetric BCD along the 3 axes was not significantly different between UEV and BTV using VBM (x, y, z-axis, p=0.893, p= 0.590, p=0.908 respectively, chi-square test).
Conclusion Contrary to intuitive concerns, UEV can inject a sufficient and more optimal BCV than BTV. Additionally, it can inject bone cement spatially, symmetrically, and evenly well-distributed without an increased rate of intradiscal leakage and SVCF compared with BTV based on VBM. Therefore, UEV could be a superior alternative surgical method with similar clinical effectiveness and safety, considering the above results and the consensus that UEV is less invasive.
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Objective Neuropathic pain is a common secondary complication of spinal cord injury (SCI). N-methyl-D-aspartate (NMDA) receptor activation is critical for hypersensitivity in neuropathic pain. This activation requires the binding of both glutamate and the D-serine co-agonist to the NMDA glycine site. We evaluated the effects of D-serine on neuropathic pain after SCI and explored the underlying molecular mechanisms.
Methods Anesthetized rats underwent T9 spinal cord contusion (130 kdyn). D-serine (500 and 1,000 mg/kg) and MK-801 hydrogen maleate (2.0 mg/kg) were injected daily for 2 weeks, starting the day after SCI. Functional outcomes were assessed according to the Basso, Beattie, and Bresnahan scale, while histological outcomes were evaluated based on lesion volume and spared tissue area. Mechanical allodynia and thermal hyperalgesia were evaluated by measuring the withdrawal threshold of a von Frey filament and hot/cold plate latency. Western blotting was performed to determine the expression levels of Trpv1, Nav1.9, calcitonin gene-related peptide (CGRP), and β-actin in damaged tissue.
Results The withdrawal threshold values and latency of the D-serine group were significantly lower than those of the noninjection group. The MK-801 group showed higher threshold values and latencies than the other groups. Western blotting showed increased Nav1.9 and Trpv1 levels and lower CGRP levels in the D-serine group, whereas the MK-801 group showed the opposite results.
Conclusion D-serine increases neuropathic pain after traumatic SCI by mediating the NMDA receptor. NMDA receptor antagonists alleviate neuropathic pain after traumatic SCI.
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Objective This study compared the radiological and clinical outcomes with transforaminal lumbar interbody fusion (TLIF) to evaluate the effect of indirect decompression through oblique lumbar interbody fusion (OLIF) as revision surgery.
Methods We enrolled patients who underwent single-level fusion with revision surgery at the same level as the previous decompression level. We retrospectively reviewed 25 patients who underwent OLIF from 2017 to 2018 and 25 who received TLIF from 2014 to 2018. Radiologic and clinical outcomes were evaluated by cross-sectional area (CSA) of the spinal canal, thickness and area of ligamentum flavum (LF), subsidence, disc height, fusion rate, Oswestry Disability Index (ODI), and visual analogue scale (VAS).
Results Compared with OLIF, the thickness and area of the LF after surgery were significantly less in TLIF, and the resulting CSA extension was also significantly higher. However, both groups showed improvement in ODI and VAS after surgery, and there was no difference between the groups. Complications related to the posterior approach in TLIF were 4 cases, and in OLIF, there were 2 cases that underwent additional posterior decompression surgery and 6 cases of transient paresthesia.
Conclusion Since complications associated with the posterior approach can be avoided, OLIF is a safer and useful minimally invasive surgery. Therefore, appropriate indications are applied, OLIF is a good alternative to TLIF when revision surgery is considered.
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Objective To evaluate which radiologic parameters affect clinical outcomes in patients underwent posterior C1–2 fusion for atlantoaxial dislocation.
Methods From January 2014 to December 2017, among 98 patients underwent C1–2 posterior fusion, patients with previous cervical surgery or extending to subaxial spine or basilar invagination were excluded. Finally, 38 patients were included. O–C2, C1–2, C1–C7, C2–C7 cobb angle (CA), T1 slope, C1–7, C2–7 sagittal vertical axis (SVA), and posterior atlantodental interval (PADI) were measured at preoperative and postoperative 1 year. The difference between postoperative and preoperative values for each parameter was designated as Δvalue. Postoperative subaxial kyphosis (PSK) was defined to decrease ≥ 10° at subaxial spine. Visual analogue scale (VAS), Japanese Orthopedic Association (JOA) score, Neck Disability Index (NDI) were used to evaluate clinical outcomes.
Results Mean age was 54.4 ± 15.9. Male to female was 14 to 24. Of radiologic parameters, C1–7 SVA and PADI were significantly changed from 26.4 ± 12.9 mm, 17.1 ± 3.3 mm to 22.6 ± 13.0 mm, 21.6 ± 3.4 mm. ΔC1–2 CA was correlated with ΔC1–7 CA and ΔC2–7 SVA. ΔPADI correlates with ΔO–C2 CA. VAS correlates with ΔC1–7 CA (p = 0.03). JOA score also correlates with ΔC2–7 SVA (p = 0.02). NDI was associated with ΔPADI (p < 0.01). The incidence of PSK was 23.7%, and not significant with clinical outcomes.
Conclusion ΔC1–2 CA was correlated with ΔC1C7 CA, ΔC2–7 SVA. ΔC1–7 CA, ΔC2–7 SVA, and ΔPADI were the key radiologic parameters to influence clinical outcomes. Postoperative C1–2 angle should be carefully determined as a factor affecting clinical outcomes and cervical sagittal alignment.
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Objective Oblique lumbar interbody fusion (OLIF) involves inserting large cages into the interbody disc space. This expands the spinal canal and neural foramen by stretching the ligament flavum and releasing the facet joint, resulting in indirect neural decompression. Our objective was to investigate the changes in the spinal canal and ligament flavum over time after OLIF.
Methods This was a prospective observational study involving 30 patients who underwent OLIF L4–5 between 2015 and 2018. In total, 27 of the 30 patients underwent preoperative, early follow-up ( < 5 days), and late follow-up (10–14 months) magnetic resonance imaging to measure the area of the spinal canal and ligament flavum. Based on the results, the patients were divided into subsidence and nonsubsidence groups for further analysis.
Results After OLIF, the spinal canal area gradually increased during the preoperative, early postoperative, and late postoperative periods (p < 0.001). The thickness and area of the ligament flavum decreased gradually over the same periods (p < 0.001). Low-grade subsidence (2–4.4 mm) did not influence the effects on the spinal canal and ligament.
Conclusion After OLIF, the spinal canal and ligament flavum gradually change, which is effective for indirect neural decompression. In addition, the effects of low-grade subsidence on the remodeling of the spinal canal and ligament flavum are insignificant.
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Surgical treatment of spondylolisthesis by oblique lumbar interbody fusion and transpedicular screw fixation: Comparison between conventional double position versus navigation-assisted single lateral position Junghoon Han, Chang-Min Ha, Woon Tak Yuh, Young San Ko, Jun-Hoe Kim, Tae-Shin Kim, Chang-Hyun Lee, Sungjoon Lee, Sun-Ho Lee, Asfandyar Khan, Chun Kee Chung, Chi Heon Kim, Mohamed El-Sayed Abdel-Wanis PLOS ONE.2023; 18(9): e0291114. CrossRef
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Objective Total en bloc spondylectomy (TES) is a curative surgical method for spinal tumors. After resecting the 3 spinal columns, reconstruction is of paramount importance. We present cases of mechanical failure and suggest strategies for salvage surgery.
Methods The medical records of 19 patients who underwent TES (9 for primary tumors and 10 for metastatic tumors) were retrospectively reviewed. Previously reported surgical techniques were used, and the surgical extent was 1 level in 16 patients and 2 levels in 3 patients. A titanium-based mesh-type interbody spacer filled with autologous and cadaveric bone was used for anterior support, and a pedicle screw/rod system was used for posterior support. Radiotherapy was performed in 11 patients (pre-TES, 5; post-TES, 6). They were followed up for 59 ± 38 months (range, 11–133 months).
Results During follow-up, 8 of 9 primary tumor patients (89%) and 5 of 10 metastatic tumor patients (50%) survived (mean survival time, 124 ± 8 months vs. 51 ± 13 months; p = 0.11). Mechanical failure occurred in 3 patients (33%) with primary tumors and 2 patients (20%) with metastatic tumors (p = 0.63). The mechanical failure-free time was 94.4 ± 14 months (primary tumors, 95 ± 18 months; metastatic tumors, 68 ± 16 months; p = 0.90). Revision surgery was performed in 4 of 5 patients, and bilateral broken rods were replaced with dual cobalt-chromium alloy rods. Repeated rod fractures occurred in 1 of 4 patients 2 years later, and the third operation (with multiple cobalt-chromium alloy rods) was successful for over 6 years.
Conclusion Considering the difficulty of reoperation and patients’ suffering, preemptive use of a multiple-rod system may be advisable.
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Objective To analyze the electrical resistance of a newly developed neuromonitoring pedicle screw (Neuro-PS) and to verify the electrophysiologic properties of the Neuro-PS in a pig model.
Methods We developed 2 types of the Neuro-PS in which a gold lead was located internally (type I) and externally (type II). We measured the electrical resistance of the Neuro-PS and the conventional screw and analyzed the electrical thresholds of triggered EMG (t-EMG) of each screw by intentionally penetrating the medial pedicle wall and contacting the exiting nerve root in a pig model.
Results The electrical resistances of the Neuro-PS were remarkably lower than that of the conventional screw. In electrophysiologic testing, only the type II Neuro-PS under the leadnerve contact condition showed a significantly lower stimulation threshold as compared to the conventional screw.
Conclusion The Neuro-PS demonstrated lower electrical resistances than the conventional screw. The type II Neuro-PS under the lead-nerve contact condition showed a significantly lower stimulation threshold compared to that of the other screws in the t-EMG test.
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The goal of acute spinal cord injury (SCI) management is to reduce secondary injuries and improve neurological recovery after its occurrence. This review aimed to explore the literature regarding hemodynamic management to reduce ischemic secondary injury and improve neurologic outcome following acute SCI. The PubMed database was searched for studies investigating blood flow, mean arterial pressure (MAP), and spinal cord perfusion pressure after SCI. The 2013 guidelines of the American Association of Neurological Surgeons/Congress of Neurological Surgeons recommended maintaining MAP at 85–90 mmHg for 7 days after SCI to potentially improve outcome. However, this recommendation was based on weak evidence for neurologic benefit. The maintenance of MAP will typically require vasopressors, which may have their own set of complications. More recently, studies have suggested the potential importance of considering spinal cord perfusion pressure in addition to the MAP. Further research on the hemodynamic management of acute SCI is required to determine how to optimize neurologic recovery. Evidence-based guidelines for hemodynamic management should acknowledge the gaps in knowledge and the limitations of the current literature.
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Objective Ligamentum flavum (LF) is an important anatomical structure for prevention of postoperative adhesions, but the opening of LF is necessary for percutaneous endoscopic lumbar interlaminar discectomy (PEID). Although the defect in LF is small with conventional PEID, the defect could be minimized with LF splitting technique. The objective of this study was to compare clinical outcomes of PEID with opening of LF versus splitting of LF.
Methods A retrospective study was performed for patients underwent PEID for L5–S1. PEID with the opening of LF (open-group) was performed for 55 patients and with splitting of LF (split-group) was performed for 34 patients. The defect of LF in Open-group was 3–5 mm, but the defect was negligible in split-group because the split LF was reapproximated by its elasticity. Clinical outcomes were evaluated with Korean version of the Oswestry Disability Index (K-ODI) and visual analogue pain scores for back (VASB) and leg (VASL). The changes of clinical outcomes during postoperative 24 months between groups were evaluated with linear mixed-effects model.
Results The clinical outcomes were similar between groups for K-ODI (p=0.98), VASB (p=0.52), and VASL (p=0.59). Each outcome demonstrated significant improvement from preoperative baseline throughout the postoperative 24 months (p<0.05). Complications included recurrence in 4 patients and dural tear in 1 in open-group (9.1%), and residual disc herniation in 2 patients and transient weakness in 1 in split-group (8.8%).
Conclusion Splitting versus opening LF in PEID may be left to the surgeon’s discretion. The potential risks and benefits of LF handling should be considered when performing this surgical technique in PEID.
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Full-Endoscopic Lumbar Discectomy Approach Selection Vit Kotheeranurak, Wongthawat Liawrungrueang, Javier Quillo-Olvera, Christoph J. Siepe, Zhen Zhou Li, Pramod V. Lokhande, Gun Choi, Yong Ahn, Chien-Min Chen, Kyung-Chul Choi, Facundo Van Isseldyk, Vincent Hagel, Sairyo Koichi, Christoph P. Hofstetter, Dav Spine.2023; 48(8): 534. CrossRef
Narrative Review of Pathophysiology and Endoscopic Management of Basivertebral and Sinuvertebral Neuropathy for Chronic Back Pain Hyeun Sung Kim, Pang Hung Wu, Il-Tae Jang Journal of Korean Neurosurgical Society.2023; 66(4): 344. CrossRef
Comparative study of the efficacy and safety of minimally invasive interlaminar full-endoscopic discectomy versus conventional microscopic discectomy in single-level lumbar herniated intervertebral disc (ENDO-F Trial): a multicenter, prospective, randomiz Jin-Sung Kim, Jun Ho Lee, Junseok Bae, Dong Chan Lee, Sang-Ha Shin, Han Joong Keum, Young Soo Choi, Sang Soo Eun, Seung Ho Shin, Hyun Jin Hong, Ji Yeon Kim, Tae Hyun Kim, Woojung Lim, Junghoon Kim, Sang-Min Park, Hyun-Jin Park, Hong-Jae Lee Journal of Orthopaedic Surgery and Research.2022;[Epub] CrossRef
Percutaneous endoscopic lumbar discectomy via the medial foraminal and interlaminar approaches: A comparative study with 2-year follow-up Sen Huang, Zhenfei Wang, Long Xu, Jinhui Bu, Bo He, Mengjiao Xia, Tao Chen, Juan Gao, Guangpu Liu, Ru Niu, Chao Ma, Guangwang Liu Frontiers in Surgery.2022;[Epub] CrossRef
Technical Considerations of Interlaminar Approach for Lumbar Disc Herniation Kuo-Tai Chen, Chun Tseng, Li-Wei Sun, Kai-Sheng Chang, Chien-Min Chen World Neurosurgery.2021; 145: 612. CrossRef
Nonsurgical treatment outcomes for surgical candidates with lumbar disc herniation: a comprehensive cohort study Chi Heon Kim, Yunhee Choi, Chun Kee Chung, Ki-Jeong Kim, Dong Ah Shin, Youn-Kwan Park, Woo-Keun Kwon, Seung Heon Yang, Chang Hyun Lee, Sung Bae Park, Eun Sang Kim, Hyunsook Hong, Yongeun Cho Scientific Reports.2021;[Epub] CrossRef
Overview of Tips in Overcoming Learning Curve in Uniportal and Biportal Endoscopic Spine Surgery Pang Hung Wu, Hyeun Sung Kim, Dae Jung Choi, Yu-Heng Tan Gamaliel Journal of Minimally Invasive Spine Surgery and Technique.2021; 6(Suppl 1): S84. CrossRef
Dural leakage due to ipsilateral needle placement for spinal level localization in unilateral decompression surgery: A case report Lukas Andereggen, Markus M. Luedi Surgical Neurology International.2021; 12: 205. CrossRef
A Narrative Review of Development of Full-Endoscopic Lumbar Spine Surgery Pang Hung Wu, Hyeun Sung Kim, Il-Tae Jang Neurospine.2020; 17(Suppl 1): S20. CrossRef
Treatment of high-iliac-crest L5-S1 lumbar disc herniation via a transverse process endoscopic transforaminal approach Zuowei Wang, Zan Chen, Hao Wu, Xingwen Wang, Kai Wang, Wanru Duan, Jian Guan, Zhenlei Liu, Fengzeng Jian Clinical Neurology and Neurosurgery.2020; 197: 106087. CrossRef
Current and Future of Endoscopic Spine Surgery: What are the Common Procedures we Have Now and What Lies Ahead? Hyeun Sung Kim, Pang Hung Wu, Il-Tae Jang World Neurosurgery.2020; 140: 642. CrossRef
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