Clinical and radiological outcome of anterior-posterior fusion versus transforaminal lumbar interbody fusion for symptomatic disc degeneration: a retrospective comparative study of 133 patients

Brief review

이 논문은 전-후방 경유  유합술 대 추간공경유 요추유합술의 임상적, 방사선학적 결과를 비교한 논문으로, 두 수술을 받은 총 133명의 환자에 대해 차트리뷰와 설문등을 통해 수술 후 환자의 상태를 평가했습니다. 

만족도, 삶의 질 평가점수, 일상생활가능정도는 두 그룹이 비슷하고 수술시간, 재원일수, 출혈량, 수술 중 합병증 률은 전-후방경유 유합술을 받은 환자들이 더 높은 결과를 보여줬습니다. 

 결론부분에서 특이한 점은 없었고 위의 수술 후 결과를 요약한 내용과, 요추 유합술 후의 결과에 영향을 미칠 수 있는 요소들이 매우 많다는 일반적인 사실만 나와있습니다.

*Title: Clinical and radiological outcome of anterior-posterior fusion versus transforaminal lumbar interbody fusion for symptomatic disc degeneration: a retrospective comparative study of 133 patients.

전-후방 경유  유합술 대 추간공경유 요추유합술의 임상적, 방사선학적 결과: 133명 환자의 후향적 비교연구.

*Author: Antonio A. Faundez, James D. Schwender, Yair Safriel, Thomas J. Gilbert, Amir A. Mehbod, Francis Denis, Ensor E. Transfeldt, Jill M. Wroblewskia

*Bibliography: Eur Spine J (2009) 18:203–211

Background

There are many data compare anterior/posterior spine fusion (APF) and transforaminal lumbar interbody fusion (TLIF).

*Problem: Only few studies from one institution compares the two techniques.

Method

▶Subject number: 133 patients (68 APF + 65 TLIF)

▶Inclusion criteria:

-Had symptomatic disc degeneration of the lumbar spine.

-Only those with one or two-level surgeries.

▶Evaluation method:

1. Clinical chart and radiologic reviews

2. fusion solidity assessed

3. functional outcomes:

·SF-36(pre, post op)

·Oswestry Disability Index (ODI)

·Satisfaction questionnaire

-The minimum follow-up period: 24 months.

Results

1. Operating Time, hospital stay: less in the TLIF group.

2. Blood loss: slightly less in the TLIF group

3. Complications: Intra-operative- higher in the APF group (due to vein lacerations)

    Postoperative- higher in the TLIF group

    (due to graft material extruding against the nerve root or wound drainage)

4. The pseudarthrosis** rate: statistically equal

5. functional outcomes:

-SF-36: signifiicant improvements in both groups.

-Mean ODI scores: 33.5 (APF), 39.5 (TLIF group)

-Satisfaction rate: equal for the two groups.

Conclusion

-There are numerous, distinctive factors influencing results of each spinal fusion approach.

** pseudarthrosis: 위관절 혹은 가관절. -골절부의 뼈가 잘 유합되지 않아 마치 관절처럼 움직이는 상태. 골절 후 골 고정이 잘못 되거나, 골절부가 세균에 감염되었을 때 발생한다.

Factors affecting dynamic foraminal stenosis in the lumbar spine

2nd journal review

*Title: Factors affecting dynamic foraminal stenosis in the lumbar spine

*Author: Vijay Singh,MD, Scott R. Montgomery,MD, Bayan Aghdasi,BA, Hirokazu Inoue,MD,PhD, Jeffrey C.Wang,MD, Michael D. Daubs,MD

*Bibliography: Spine J. 2013 Sep;13(9):1080-7.


Background Context: Minimal in vivo data exists quantifying changes in foraminal area(FA) as the spine moves from flextion to extension in the lumbar spine.

Purpose: To evaluate the relationship between foraminal stenosis and lumbar segmental 1)angular motion, 2)translational motion(TM), 3)disc bulge migration.

Study design: A retrospective radiographic study.

Patient sample: 45patients undergoing kMRI for symptoms of low back pain of radiculopathy(44years).

Outcome measures: MRI measurements of FA, angular motion, TM, disc bulge migration.

Methods:
>Study population
-45patients with clinically symptomatic low back pain or radiculopathy were reffered to lumbar kMRI.  (2011.03~2011.06)
-sex: 27males / 18females
-age: 44.7 years
-exclusion criteria: patients with unclear foraminal margins owing to rotation or scoliosis and with previous surgery, trauma, tumor, and infection.
    total 204 foramina met the inclusion criteria for analysis...

>MRI imaging protocol
-MRI of lumbar spine was performed using a 0.6-T Upright Multi-Position MRI (Fornar Corporation, Melville, NY, USA).

>MRI measurements
-Foraminal Area
1) The FA was calculated after outlining the perimeter of the neural foramen on parasagittal images using Image J software (ver. 1.45, US, National Institutes of Health, Bethesda, MD, USA)

2) assessed qualitatively using a modification of the grading system published bt Wildermuth et al.
Grade 1: normal foramina with normal foraminal epidural fat.
Grade 2: slight foraminal stenosis and deformity of epidural fat with remaining fat still completely surrounding the exiting nerve root.
Grade 3: marked foraminal stenosis with epidural fat only partially surrounding the nerve root or complete stenosis of foraminal epidural fat.

-Angular motion, TM, disc bulge
Images were evaluated with digital imaging software(MR Analyzer, ver. 2.0; TrueMRI Corporation, Bell-flower, CA, USA).
1) segmental angular motion: defined as the difference in intervertebral angles between two adjacent vertebrae from flextion to extension.
2) TM: calculated as the amount of anteroposterior movement at each vertebral level (flex to ext).
3) disc bulge: measured as the difference in the amount of disc bulging in the foramen from posterior vertebral margins at the level of foramina (flex to ext).

>Statistical analysis
-disc bulge, TM, angular motion data underwent statistical significance testing using the Shapiro-Wilk test and Mann-Whitney U test, Bonferroni inequality (p<0.05).

Results:
-There was a significant decrease in the FA from flx to neutral at all levels except L5-S1 and from neutral to ext at all levels.
-The average percent decrease in FA was 30.0%.
-Greatest decrease from flx to ext at L2-L3.
-Smallest change at L5-S1.
-The magnitude of change in FA increased as angular motion at a segment increased.
-The mean change in FA was 32.3㎟ when angular motion was less than 5º and was 75.16㎟ when angular motion exceeded 15º.
-The extent of disc bulging posteriorly in the neural foramen was also correlated with the reduction in the FA from flx to ext, but TM had no effect.

Conclusions:
-Foraminal area decreased significantly in extension compared with flexion and neutral on MRI.
-Disc bulge migration and angular motion at each level contributed to the decrease in FA(from flx to ext).
-TM was not strongly correlated to changes in FA.