Diagnostic accuracy of CT scan–based criteria compared with surgical exploration for the analysis of cervical fusion and nonunion

Bilsen, Martine van; Ullrich, Christopher G.; Ferraris, Luis; Hempfing, Axel; Hitzl, Wolfgang; Mayer, Michaël; Koller, Heiko

doi:10.3171/2019.12.spine191011

Cited by 5 publications

(6 citation statements)

References 20 publications

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“…However, validating the clinical efficacy of diagnostic tests for pseudoarthrosis is challenging. Numerous studies have employed open surgical exploration as the gold standard against which alternative fusion assessment methods are compared, (23, 30, 31, 90, 91) even though there is no established validation of the accuracy and reproducibility of open surgical assessment. Other research has focused on the agreement between assessment methods and observers using specific techniques, (14) but these studies do not directly demonstrate the clinical value of a test.…”

Section: Discussionmentioning

confidence: 99%

“…The word “apparent” is used since strain in individual bone trabeculae is not being measured, and trabeculae comprising bridging bone do not always form in a straight line from the endplate to the endplate. (31, 34–36) The “apparent” strain measured between a point on the inferior endplate and a point on the superior endplate may not be equal to the tissue strain occurring in individual spicules of bridging bone. (48) Nevertheless, apparent strain may prove to be an effective metric.…”

Section: Introductionmentioning

confidence: 99%

“…While many studies use intraoperative evaluation of intervertebral movement as the reference standard for fusion assessment, this method lacks adequate validation. (12,(23)(24)(25)(26)(27)(28)(29)(30)(31) Relying on subjective, invasive intraoperative evaluations in routine clinical practice is not ideal because the applied force and the subjective assessment of motion are difficult to standardize among surgeons. The force applied by a surgeon is likely minor compared to the force exerted by patients when trying to flex and extend their spine to the maximum.…”

Section: Introduction General Backgroundmentioning

confidence: 99%

“…The remodeling phase of bone healing leads to trabecular bone within the fusion mass. (31, 33–36) It is reasonable to assume that the bone that bridges between endplates has failure properties similar to those of trabecular bone from vertebral bodies. The yield strains of trabecular bone from different anatomic sites are very similar(37), which provides confidence in the application of existing vertebral trabecular bone failure data to diagnostic tests for spine fusion.…”

Section: Introductionmentioning

confidence: 99%

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Diagnosis of spine pseudoarthrosis based on the biomechanical properties of bone

Hipp,

Mikhael,

Reitman

et al. 2024

Preprint

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BackgroundCervical spine fusion, commonly performed with generally favorable outcomes, may result in postsurgical symptoms requiring further investigation and treatment. Anterior cervical discectomy and fusion (ACDF) aims to decompress neural structures, stabilize motion segments, eliminate intervertebral motion, and promote bridging bone formation. Failure to form bridging bone may result in persistent symptoms or symptomatic pseudoarthrosis. Traditional diagnosis involves computerized tomography to detect bridging bone and/or flexion-extension radiographs to assess whether segmental motion is above specific thresholds. This paper proposes a new biomechanically based diagnostic approach to address limitations in traditional diagnostic methods. The scientific basis of this approach is that bridging bone cannot occur if the strain is greater than the failure strain of the bone.MethodsFully automated methods were used to measure disc space strains. Errors in strain measurements were assessed from simulated radiographs. Measurement error combined with the reported failure strain of trabecular bone led to a proposed strain threshold for pseudoarthrosis diagnosis post-ACDF surgery. A reanalysis of previously reported flexion-extension radiographs for asymptomatic volunteers was used to assess whether flexion-extension radiographs, in the absence of fusion surgery, can be expected to provide sufficient stress on motion segments to allow for reliable strain-based fusion assessment. The sensitivity and specificity of strain- and rotation-based pseudoarthrosis diagnosis were assessed by reanalysis of previously reported post-ACDF flexion-extension radiographs, where intraoperative fusion assessments were also available. Finally, changes in strain over time were explored through the use of 9,869 flexion-extension radiographs obtained 6 weeks to 84 months post-ACDF surgery from 1,369 patients.ResultsThe estimated error in measuring disc space strain from radiographs was approximately 3%, and the reported failure strain of bridging bone was less than 2.5%. On that basis, a 5% strain threshold is proposed for pseudoarthrosis diagnosis. Good-quality flexion-extension radiographs can be expected to stress the spine sufficiently to facilitate strain-based diagnosis of pseudoarthrosis. Reanalysis of a study in which intraoperative fusion assessments were available revealed 67% sensitivity and 82% specificity for strain-based diagnosis of pseudoarthrosis, which is comparable to rotation-based diagnosis. Analysis of post-ACDF flexion-extension radiographs revealed rapid strain reduction for up to 24 months, followed by a slower decrease for up to 84 months. When rotation is less than 2 degrees, the strain-based diagnosis differs from the rotation-based diagnosis in approximately 14% of the cases.DiscussionSteps for standardizing strain-based diagnosis of pseudoarthrosis are proposed based on the failure strain of bone, measurement error, and retrospective data. These steps include obtaining high-quality flexion-extension studies, the application of proposed diagnostic thresholds, and the use of image stabilization for conclusive diagnosis, especially when motion is near thresholds. The necessity for an accurate diagnosis with minimal radiation exposure underscores the need for further optimization and standardization in diagnosing pseudoarthrosis following ACDF surgery.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introduction General Backgroundmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Diagnosis of spine pseudoarthrosis based on the biomechanical properties of bone

Hipp,

Mikhael,

Reitman

et al. 2024

Preprint

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“…Radiographs after ORIF should be scrutinized for fracture healing, hardware failure, collapse, and avascular necrosis (AVN) of the head. Advanced imaging such as computerized tomography (CT) scan can be useful to validate osseous integration and bony ingrowth between the fibular strut and cortex (Figure 3 ) [ 20 ].…”

Section: Case Presentationmentioning

confidence: 99%

The Corkscrew Technique for Removing a Fibular Strut Allograft From the Proximal Humerus

Skura¹,

Glazier²,

Schuette³

et al. 2022

Cureus

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A fibular strut allograft is a reliable option for augmentation in open reduction internal fixation (ORIF) of proximal humerus fractures, but techniques to remove a fibular strut during revision shoulder arthroplasty are limited. Currently published techniques on extracting fibular strut grafts from humeral shafts include using a Midas burr, flexible osteotomes, humeral shaft osteotomy, and reaming. To our knowledge there has not been a technique that uses a corkscrew to remove the fibular strut from the proximal humerus in preparation for revision shoulder arthroplasty. This is a case report and description of a simple and reproducible technique that can be implemented in the setting of conversion from a proximal humerus lateral locking plate with fibular strut allograft to shoulder arthroplasty.

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Successful fusion versus pseudarthrosis after spinal instrumentation: a comprehensive imaging review

et al. 2022

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Diagnostic accuracy of CT scan–based criteria compared with surgical exploration for the analysis of cervical fusion and nonunion

Cited by 5 publications

References 20 publications

Diagnosis of spine pseudoarthrosis based on the biomechanical properties of bone

Diagnosis of spine pseudoarthrosis based on the biomechanical properties of bone

The Corkscrew Technique for Removing a Fibular Strut Allograft From the Proximal Humerus

Successful fusion versus pseudarthrosis after spinal instrumentation: a comprehensive imaging review

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