A Systematic Review of Treatment Strategies for the Prevention of Junctional Complications After Long-Segment Fusions in the Osteoporotic Spine

Study Design Systematic review. Objectives Review the surgical techniques and construct options aimed at improving the biomechanical strength of cervical constructs. Methods A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of the MEDLINE, Embase, and Cochrane Library databases was performed to identify all studies examining biomechanical strategies utilized in the osteoporotic cervical spine. Screening was performed in duplicate for all stages of the review process. Results An initial search returned 3887 articles. After deletion of duplications and review of abstracts and full text, 39 articles met inclusion criteria. Overall, the surgical techniques reviewed aimed at obtaining rigid fixation in the setting of poor bone quality, or dispersing the forces at the bone-implant interface. We identified 6 key techniques to improve biomechanical fixation. These include bicortical fixation, appropriate screw selection (size and trajectory), PMMA augmentation, load sharing techniques, consideration of ancillary fixation around the occipitocervical junction, and supplementing the construct with post-operative collar or halo. Conclusion The summation of the literature highlights a framework of modalities available to surgeons to improve biomechanical fixation in the cervical spine. While these may improve construct strength in the setting of osteoporosis, there is a paucity of evidence available to make recommendations in this patient population.

Section: Resultsmentioning

confidence: 99%

A Review of Strategies to Improve Biomechanical Fixation in the Cervical Spine

Oitment

Thornley

Koziarz

et al. 2022

“…46,[52][53][54] Osteoporosis and bone mineral density have, on the other hand, consistently demonstrated to be a major risk factor for instrumentation failure and proximal junctional failure. [55][56][57][58] Unfortunately, none of the current studies listed herein are stratified by bone mineral density measurements, and thus no conclusions can be made regarding its effect on decompression alone in DLS. This is a major potential area of study.…”

Section: Discussionmentioning

confidence: 99%

Decompression Alone in the Setting of Adult Degenerative Lumbar Scoliosis and Stenosis: A Systematic Review and Meta-Analysis

Echt

Ramos

Geng

et al. 2022

Self Cite

Study Design Systematic review and meta-analysis. OBJECTIVESSurgical decompression alone for patients with neurogenic leg pain in the setting of degenerative lumbar scoliosis (DLS) and stenosis is commonly performed, however, there is no summary of evidence for outcomes. Methods A systematic search of English language medical literature databases was performed for studies describing outcomes of decompression alone in DLS, defined as Cobb angle >10˚, and 2-year minimum follow-up. Three outcomes were examined: 1) Cobb angle progression, 2) reoperation rate, and 3) ODI and overall satisfaction. Data were pooled and weighted averages were calculated to summarize available evidence. Results Across 15 studies included in the final analysis, 586 patients were examined. Average preoperative and postoperative Cobb angles were 17.6˚ (Range: 12.7 - 25˚) and 18.0 (range 14.1 - 25˚), respectively. Average change in Cobb angle was an increase of 1.8˚. Overall rate of reoperation ranged from 3 to 33% with an average of 9.7%. Average ODI before surgery, after surgery, and change in scores were 56.4%, 27.2%, and an improvement of 29% respectively. Average from 8 studies that reported patient satisfaction was 71.2%. Conclusions Current literature on decompression alone in the setting of DLS is sparse and is not high quality, limited to patients with small magnitude of lumbar coronal Cobb angle, and heterogenous in the type of procedure performed. Based on available evidence, select patients with DLS who undergo decompression alone had minimal progression of Cobb angle, relatively low reoperation rate, and favorable patient-reported outcomes.

“…20 As there are no BMDadjusted alignment goals, surgeons need to aim for patientspecific alignment thresholds. 47 To avoid adjacent segment fractures, prophylactic vertebroplasty of the UIV or the UIV plus one additional vertebra may reduce proximal junctional vertebra collapse and associated reoperation rates especially in the surgical treatment of degenerative pathologies. 48 Furthermore, posterior construct stiffness may influence mechanical stresses on the proximal junction.…”

Section: Smentioning

confidence: 99%

Avoiding Spinal Implant Failures in Osteoporotic Patients: A Narrative Review

Schömig

Becker

Schönnagel

et al. 2023

Study design Narrative review. Objectives With an aging population, the prevalence of osteoporosis is continuously rising. As osseous integrity is crucial for bony fusion and implant stability, previous studies have shown osteoporosis to be associated with an increased risk for implant failure and higher reoperation rates after spine surgery. Thus, our review’s purpose was to provide an update of evidence-based solutions in the surgical treatment of osteoporosis patients. Methods We summarize the existing literature regarding changes associated with decreased bone mineral density (BMD) and resulting biomechanical implications for the spine as well as multidisciplinary treatment strategies to avoid implant failures in osteoporotic patients. Results Osteoporosis is caused by an uncoupling of the bone remodeling cycle based on an unbalancing of bone resorption and formation and resulting reduced BMD. The reduction in trabecular structure, increased porosity of cancellous bone and decreased cross-linking between trabeculae cause a higher risk of complications after spinal implant-based surgeries. Thus, patients with osteoporosis require special planning considerations, including adequate preoperative evaluation and optimization. Surgical strategies aim towards maximizing screw pull-out strength, toggle resistance, as well as primary and secondary construct stability. Conclusions As osteoporosis plays a crucial role in the fate of patients undergoing spine surgery, surgeons need to be aware of the specific implications of low BMD. While there still is no consensus on the best course of treatment, multidisciplinary preoperative assessment and adherence to specific surgical principles help reduce the rate of implant-related complications.