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ACS vs. Iliac Crest Bone Graft for Posterior Cervical Arthrodesis
24S
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S-205S
45. Minimally Invasive Posterior C1-C2 Screw Fixation Through an Anatomical Corridor Preserving Occipital-Cervical Tension Band: Prospective 21 Months Clinical and Radiological Study Roberto Diaz, MD1, Miguel Berbeo2, Luis Villalobos2, Manuel Vergara, MD2; 1Department of Neurosurgery, Hospital Universitario San Ignacio, Universidad Javeriana, Bogota, Colombia; 2Bogota, Colombia BACKGROUND CONTEXT: The C1-C2 joint is affected by multiple entities that may produce biomechanical instability. Optimal management for atlanto-axial instability has been searched by ways of different surgical techniques with different results, generating discussion between second effects of a particular treatment. PURPOSE: In the following study, we propose a minimally invasive (MIS) C1-C2 fusion technique through the anatomical corridor between the posterior major rectus capitis and the inferior obliquus capitis. We performed a C1 lateral-mass screws and C2 pedicular screws instrumentation. The use of a MIS technique to perform posterior C1-C2 fixation, reducing muscle devascularization and denervation would preserve the medial tension band. This means less intraoperative blood loss, less postoperative pain and shorter hospital stay, also better postoperative cervical spine stability. STUDY DESIGN/SETTING: Prospective non randomized single center study. PATIENT SAMPLE: 9 patients with C1-C2 instability do to dens fracture and/or reumatoid arthritis atlanto axial subluxation were enrolled. OUTCOME MEASURES: Operative time, blood loss and hospitalization time were recorded. Subjects were evaluated preoperatively and postoperatively at 1, 3, 6, 12 and 24 months. Analysis consists of clinical outcomes and radiological assessment. METHODS: We performed in all cases a minimally invasive trans-muscular approach through a 25 mm bilateral paramedian skin incision, using the access MIS platform Maxcess II; and subsequent placing screws according to the modified Harms technique. This approach uses a progressive tubular dilators system through the superficial nucal musculature (trapezius and semispinalis capitis) and then through the anatomical corridor. A 4.0 mm diameter poliaxial screws are inserted using Harm’s technique. The articular surfaces of C1 and C2 are decorticated using curettes and demineralized bone matrix mixed with bone marrow aspirated is placed inside the joint. The same procedure is made in the contra lateral side in the same way. RESULTS: There were no intra-operative and postoperative complications. All patients (100%) recovered uneventfully and recovery of the preoperative symptoms. Patients experienced minimal post-operative pain and were discharged before 46,8 hours mean time. CONCLUSIONS: As our experience in minimally invasive techniques improves, we can offer our patients less morbid treatment options with similar or better results to those achieved with conventional procedures. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.056
46. Perioperative Complications of rhBMP-2/ACS vs. Iliac Crest Bone Graft for Posterior Cervical Arthrodesis Charles Crawford, III, MD1, Leah Carreon, MD, MSC2, Mark McGinnis, MD1, Mitchell Campbell, MD2, Steven Glassman, MD2; 1University of Louisville, Louisville, KY, USA; 2Leatherman Spine Center, Louisville, KY, USA BACKGROUND CONTEXT: There is substantial use of rhBMP-2/ACS as a bone graft substitute for spine fusions outside the FDA approved indication of anterior lumbar interbody fusion. Efficacy for inducing fusion and avoidance of iliac crest donor site complications are frequent reasons cited for its use. Previous studies have reported use in the anterior lumbar spine, the posterior lumbar spine, and in the anterior cervical spine. Sitespecific perioperative complications that have been reported, especially
with use in the anterior cervical spine, confirm that safety and efficacy should be established for specific anatomical sites and clinical indications. PURPOSE: To determine the risk of perioperative complications using rhBMP-2/ACS for posterior cervical fusion compared to ICBG. STUDY DESIGN/SETTING: Retrospective evaluation of perioperative complications with recombinant human bone morphogenetic protein-2 on an absorbable collagen sponge (rhBMP-2/ACS) versus iliac crest bone graft (ICBG) for instrumented posterior cervical fusion. PATIENT SAMPLE: Seventy-seven consecutive patients who underwent instrumented posterior cervical fusion. OUTCOME MEASURES: Demographic, surgical, and perioperative complication data. METHODS: From July 2002 to February 2005, a consecutive series of patients who underwent instrumented posterior cervical fusion were identified. Patients received either rhBMP-2/ACS or ICBG based on the discretion of the surgeon. Patients were excluded if they had a preoperative diagnosis of trauma, tumor or infection, or if they underwent a concomitant anterior procedure. Seventy-seven patients met the inclusion criteria. Forty-one of these patients received rhBMP-2/ACS and thirty-six received ICBG. Standard demographic, surgical, and perioperative complication data were collected from the medical records. RESULTS: There were no significant differences in age, gender distribution, smoking status, number of surgical levels, blood loss, operative time, nor length of stay between the two groups. There were more posterior cervical wound complications requiring treatment in the rhBMP-2/ACS group (6, 14.6%) versus the ICBG group (1, 2.8%), although this was not statistically significant (p50.113). One patient (2.8%) in the ICBG group had a wound complication at the iliac crest donor site. Additional perioperative complications were noted in three patients (7.3%) in the ICBG group and none in the rhBMP-2/ACS group. CONCLUSIONS: The higher incidence of posterior cervical wound complications in the rhBMP-2/ACS group, although not statistically significant, may be related to an inflammatory response to rhBMP-2. This potential risk must be weighed against the elimination of donor site complications associated with ICBG harvesting, and considered in light of ultimate clinical outcome. Additional studies are needed to clarify this issue, as well as to determine optimal dosing and carrier for usage in the posterior cervical spine. FDA DEVICE/DRUG STATUS: INFUSE: Not approved for this indication. doi: 10.1016/j.spinee.2009.08.057
47. Cervical Endplate and Facet Arthrosis: An Anatomic Study of 234 Postmortem Specimens Daniel Master, MD1, Ryan Garcia, MD1, Erik Schnaser, MD1, Jason Eubanks, MD1, Sheeraz Qureshi, MD2, Nicholas Ahn, MD1; 1Case Western Reserve University, Cleveland, OH, USA; 2Mount Sinai School of Medicine, New York, NY, USA BACKGROUND CONTEXT: Cervical endplate and facet arthrosis are common radiographic findings which increase with age and which have both been linked to pain. However, the prevalence of and temporal relationship between cervical endplate and facet arthrosis has not been well defined. In determining the mechanism with which cervical spondylosis occurs, knowledge of whether the facets joints or disks fail first may be of benefit for predicting failure of cervical segments and also for development of future treatments. PURPOSE: The purpose of this study was to determine the prevalence of and relationship between cervical endplate and facet arthrosis in a large population sample. STUDY DESIGN/SETTING: A cross-sectional, observational study was performed on adult cadaveric specimens with that were randomly selected from the Hamann Todd Collection in the Cleveland Museum of Natural History. This collection houses the dried, disarticulated spines from over 3100 individuals who died in Cleveland, Ohio between the years of 1893-1938.
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S-205S
45. Minimally Invasive Posterior C1-C2 Screw Fixation Through an Anatomical Corridor Preserving Occipital-Cervical Tension Band: Prospective 21 Months Clinical and Radiological Study Roberto Diaz, MD1, Miguel Berbeo2, Luis Villalobos2, Manuel Vergara, MD2; 1Department of Neurosurgery, Hospital Universitario San Ignacio, Universidad Javeriana, Bogota, Colombia; 2Bogota, Colombia BACKGROUND CONTEXT: The C1-C2 joint is affected by multiple entities that may produce biomechanical instability. Optimal management for atlanto-axial instability has been searched by ways of different surgical techniques with different results, generating discussion between second effects of a particular treatment. PURPOSE: In the following study, we propose a minimally invasive (MIS) C1-C2 fusion technique through the anatomical corridor between the posterior major rectus capitis and the inferior obliquus capitis. We performed a C1 lateral-mass screws and C2 pedicular screws instrumentation. The use of a MIS technique to perform posterior C1-C2 fixation, reducing muscle devascularization and denervation would preserve the medial tension band. This means less intraoperative blood loss, less postoperative pain and shorter hospital stay, also better postoperative cervical spine stability. STUDY DESIGN/SETTING: Prospective non randomized single center study. PATIENT SAMPLE: 9 patients with C1-C2 instability do to dens fracture and/or reumatoid arthritis atlanto axial subluxation were enrolled. OUTCOME MEASURES: Operative time, blood loss and hospitalization time were recorded. Subjects were evaluated preoperatively and postoperatively at 1, 3, 6, 12 and 24 months. Analysis consists of clinical outcomes and radiological assessment. METHODS: We performed in all cases a minimally invasive trans-muscular approach through a 25 mm bilateral paramedian skin incision, using the access MIS platform Maxcess II; and subsequent placing screws according to the modified Harms technique. This approach uses a progressive tubular dilators system through the superficial nucal musculature (trapezius and semispinalis capitis) and then through the anatomical corridor. A 4.0 mm diameter poliaxial screws are inserted using Harm’s technique. The articular surfaces of C1 and C2 are decorticated using curettes and demineralized bone matrix mixed with bone marrow aspirated is placed inside the joint. The same procedure is made in the contra lateral side in the same way. RESULTS: There were no intra-operative and postoperative complications. All patients (100%) recovered uneventfully and recovery of the preoperative symptoms. Patients experienced minimal post-operative pain and were discharged before 46,8 hours mean time. CONCLUSIONS: As our experience in minimally invasive techniques improves, we can offer our patients less morbid treatment options with similar or better results to those achieved with conventional procedures. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.056
46. Perioperative Complications of rhBMP-2/ACS vs. Iliac Crest Bone Graft for Posterior Cervical Arthrodesis Charles Crawford, III, MD1, Leah Carreon, MD, MSC2, Mark McGinnis, MD1, Mitchell Campbell, MD2, Steven Glassman, MD2; 1University of Louisville, Louisville, KY, USA; 2Leatherman Spine Center, Louisville, KY, USA BACKGROUND CONTEXT: There is substantial use of rhBMP-2/ACS as a bone graft substitute for spine fusions outside the FDA approved indication of anterior lumbar interbody fusion. Efficacy for inducing fusion and avoidance of iliac crest donor site complications are frequent reasons cited for its use. Previous studies have reported use in the anterior lumbar spine, the posterior lumbar spine, and in the anterior cervical spine. Sitespecific perioperative complications that have been reported, especially
with use in the anterior cervical spine, confirm that safety and efficacy should be established for specific anatomical sites and clinical indications. PURPOSE: To determine the risk of perioperative complications using rhBMP-2/ACS for posterior cervical fusion compared to ICBG. STUDY DESIGN/SETTING: Retrospective evaluation of perioperative complications with recombinant human bone morphogenetic protein-2 on an absorbable collagen sponge (rhBMP-2/ACS) versus iliac crest bone graft (ICBG) for instrumented posterior cervical fusion. PATIENT SAMPLE: Seventy-seven consecutive patients who underwent instrumented posterior cervical fusion. OUTCOME MEASURES: Demographic, surgical, and perioperative complication data. METHODS: From July 2002 to February 2005, a consecutive series of patients who underwent instrumented posterior cervical fusion were identified. Patients received either rhBMP-2/ACS or ICBG based on the discretion of the surgeon. Patients were excluded if they had a preoperative diagnosis of trauma, tumor or infection, or if they underwent a concomitant anterior procedure. Seventy-seven patients met the inclusion criteria. Forty-one of these patients received rhBMP-2/ACS and thirty-six received ICBG. Standard demographic, surgical, and perioperative complication data were collected from the medical records. RESULTS: There were no significant differences in age, gender distribution, smoking status, number of surgical levels, blood loss, operative time, nor length of stay between the two groups. There were more posterior cervical wound complications requiring treatment in the rhBMP-2/ACS group (6, 14.6%) versus the ICBG group (1, 2.8%), although this was not statistically significant (p50.113). One patient (2.8%) in the ICBG group had a wound complication at the iliac crest donor site. Additional perioperative complications were noted in three patients (7.3%) in the ICBG group and none in the rhBMP-2/ACS group. CONCLUSIONS: The higher incidence of posterior cervical wound complications in the rhBMP-2/ACS group, although not statistically significant, may be related to an inflammatory response to rhBMP-2. This potential risk must be weighed against the elimination of donor site complications associated with ICBG harvesting, and considered in light of ultimate clinical outcome. Additional studies are needed to clarify this issue, as well as to determine optimal dosing and carrier for usage in the posterior cervical spine. FDA DEVICE/DRUG STATUS: INFUSE: Not approved for this indication. doi: 10.1016/j.spinee.2009.08.057
47. Cervical Endplate and Facet Arthrosis: An Anatomic Study of 234 Postmortem Specimens Daniel Master, MD1, Ryan Garcia, MD1, Erik Schnaser, MD1, Jason Eubanks, MD1, Sheeraz Qureshi, MD2, Nicholas Ahn, MD1; 1Case Western Reserve University, Cleveland, OH, USA; 2Mount Sinai School of Medicine, New York, NY, USA BACKGROUND CONTEXT: Cervical endplate and facet arthrosis are common radiographic findings which increase with age and which have both been linked to pain. However, the prevalence of and temporal relationship between cervical endplate and facet arthrosis has not been well defined. In determining the mechanism with which cervical spondylosis occurs, knowledge of whether the facets joints or disks fail first may be of benefit for predicting failure of cervical segments and also for development of future treatments. PURPOSE: The purpose of this study was to determine the prevalence of and relationship between cervical endplate and facet arthrosis in a large population sample. STUDY DESIGN/SETTING: A cross-sectional, observational study was performed on adult cadaveric specimens with that were randomly selected from the Hamann Todd Collection in the Cleveland Museum of Natural History. This collection houses the dried, disarticulated spines from over 3100 individuals who died in Cleveland, Ohio between the years of 1893-1938.