Study Design:Retrospective cohort study.Objective:To determine risk factors that may affect the rate of pedicle screws loosening in patients with degenerative diseases of the lumbar spine.Methods:A total of 250 patients with a low-grade spondylolisthesis and lumbar instability associated with degenerative diseases were enrolled. Preoperatively patients underwent computed tomography (CT) and cancellous bone radiodensity of a vertebral body was measured in Hounsfield units (HU). Pedicle screw fixation was used to treat patients either with a posterior fusion only or in combination with transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), and direct lateral interbody fusion (D-LIF). Minimal follow-up period accounted for 18 months. Cases with screw loosening were registered assessing association with risk factors using logistic regression.Results:The rate of screw loosening was in positive correlation with the number fused levels and decreasing bone radiodensity. Fusion with a greater load-bearing surface cage was associated with the decrease in rate of pedicle screws loosening. Incomplete reduction in case of spondylolisthesis, bilateral facet joints removal, and laminectomy performed without anterior support favored pedicle screws loosening development. The estimated model classifies correctly 79% of cases with the specificity and sensitivity accounting for 87% and 66% respectively.Conclusions:The decreasing bone radiodensity in Hounsfield units has a considerable correlation with the rate of pedicle screws loosening. On the other hand, the length of fixation and applied surgical technique including fusion type also have a significant impact on complication rate. Spinal instrumentations should be planned by taking into account all potential risk factors and not characteristics relevant to bone quality assessment alone.

Background: Despite the evident progress in treating vertebral column degenerative diseases, the rate of a so-called “failed back surgery syndrome” associated with pain and disability remains relatively high. However, this term has an imprecise definition and includes several different morbid conditions following spinal surgery, not all of which directly illustrate the efficacy of the applied technology; furthermore, some of them could even be irrelevant. Objective: To evaluate and systematize the reasons for persistent pain syndromes following surgical nerve root decompression. Study Design: Prospective, nonrandomized, cohort study of 138 consecutive patients with radicular pain syndromes, associated with nerve root compression caused by lumbar disc herniation, and resistant to conservative therapy for at least one month. The minimal period of follow-up was 18 months. Setting: Hospital outpatient department, Russian Federation Methods: Pre-operatively, patients were examined clinically, applying the visual analog scale (VAS), Oswestry Disability Index (ODI), magnetic resonance imaging (MRI), discography and computed tomography (CT). According to the disc herniation morphology and applied type of surgery, all participants were divided into the following groups: for those with disc extrusion or sequester, microdiscectomy was applied (n = 65); for those with disc protrusion, nucleoplasty was applied (n = 46); for those with disc extrusion, nucleoplasty was applied (n = 27). After surgery, participants were examined clinically and the VAS and ODI were applied. All those with permanent or temporary pain syndromes were examined applying MRI imaging, functional roentgenograms, and, to validate the cause of pain syndromes, different types of blocks were applied (facet joint blocks, paravertebral muscular blocks, transforaminal and caudal epidural blocks). Results: Group 1 showed a considerable rate of pain syndromes related to tissue damage during the intervention; the rates of radicular pain caused by epidural scar and myofascial pain were 12.3% and 26.1% respectively. Facet joint pain was found in 23.1% of the cases. Group 2 showed a significant rate of facet joint pain (16.9%) despite the minimally invasive intervention. The specificity of Group 3 was the very high rate of unresolved or recurred nerve root compression (63.0%); in other words, in the majority of cases, the aim of the intervention was not achieved. The results of the applied intervention were considered clinically significant if 50% pain relief on the VAS and a 40% decrease in the ODI were achieved. Limitations: This study is limited because of the loss of participants to follow-up and because it is nonrandomized; also it could be criticized because the dynamics of numeric scores were not provided. Conclusion: The results of our study show that an analysis of the reasons for failures and partial effects of applied interventions for nerve root decompression may help to understand better the efficacy of the interventions and could be helpful in improving surgical strategies, otherwise the validity of the conclusion could be limited because not all sources of residual pain illustrate the applied technology efficacy. In the majority of cases, the cause of the residual or recurrent pain can be identified, and this may open new possibilities to improve the condition of patients presenting with failed back surgery syndrome. Key words: microdiscectomy, nucleoplasty, epidural scar, facet joint pain, recurrent herniation, myofascial pain

PurposeTo study the possible effects of various diagnostic strategies and the relative contribution of various structures in order to determine the optimal diagnostic strategy in treating patients with noncompressive pain syndromes.Study designProspective, nonrandomized cohort study of 83 consecutive patients with noncompressive pain syndromes resistant to repeated courses of conservative treatment. The follow-up period was 18 months.ResultsNucleoplasty was effective in cases of discogenic pain; the consequences related to false positive results of the discography were significant. The most specific criterion was 80% pain relief after facet joint blocks, whereas 50% pain relief and any subjective pain relief were not associated with a significant increase in the success rate. A considerable rate of false negative results was associated with 80% pain relief, whereas 50% pain relief after facet joint blocks showed the optimal ratio of sensitivity and specificity. Facet joint pain was detected in 50.6% of cases (95% confidence interval 44.1%–66.3%), discogenic pain in 16.9% cases (95% confidence interval 9.5%–26.7%), and sacroiliac joint pain in 7.2% cases (95% confidence interval 2.7%–15%). It was impossible to differentiate the main source of pain in 25.3% of cases.ConclusionIt is rational to adjust the diagnostic algorithm to the probability of detecting a particular pain source and, in doing so, reduce the number of invasive diagnostic measures to evaluate a pain source. False positive results of diagnostic measures can negatively affect the overall efficacy of a particular technology; therefore, all reasons for the failure should be studied in order to reach an unbiased conclusion. In choosing diagnostic criteria, not only should the success rate of a particular technology be taken into consideration but also the rate of false negative results. Acceptable diagnostic criteria should be based on a rational balance of sensitivity and specificity.

Background: Nucleoplasty is a minimally invasive intervention use to perform disc decompression in cases of nerve root compression caused by disc herniation. It is important to find rational guidelines for choosing between nucleoplasty and microsurgery. Objective: To analyze factors that may impact the results of nucleoplasty, and to validate the rational guidelines between minimally invasive treatment and open surgery. Study Design: Prospective, non-randomized, cohort study with a minimal follow-up period of 18 months. Methods: Patients were given a neurological examination, visual analogue scale and Oswestry disability questionnaire, obligatory MRI, optional RCT, and discography, only before nucleoplasty. Patients have been divided into the following groups: Group 1 – patients with a disc protrusion treated with nucleoplasty (n = 46), which has been divided into Subgroup 1A, those with a disc protrusion size ≤ 5 mm (n = 24), and Subgroup 1B, those with a disc protrusion size 6 – 9 mm (n = 22); Group 2 – patients with a disc extrusion treated with nucleoplasty (n = 27); Group 3 – patients with a disc extrusion or sequester treated with microdiscectomy (n = 65). Outcome Measures: Clinically significant outcomes were a 50% relief of pain intensity and a 40% decrease of Oswestry Disability Index (ODI). Results: A decrease of pain intensity and disability was found in all groups of patients, P < 0.0001; SP (statistical power) = 99 – 100%. Subgroups 1A and 1B showed no clinically significant differences in outcome, P = 0.99; SP = 5.3. Clinically significant results: Group 1 – 78%; 95% CI (confidence interval) [66; 90%], Group 2 – 44%; 95% CI [25; 65%], Group 3 – 93%; 95% CI [85; 98%]. Total annulus disruption increases the rate of unsatisfactory results of nucleoplasty, OR (odds ratio) = 4.5; 95% CI [1.57; 12.87] (logistic regression model, P = 0.0034). Nucleoplasty performed in cases of uncontained disc herniation (disc extrusion) have a significantly higher rate of unsatisfactory results versus microdiscectomy, OR = 19.06; 95% CI [2.29; 68.73] (logistic regression model, P < 0.0001). Limitations: This study was limited by the small number of patients in each group. Conclusion: The size of the disc protrusion does not significantly affect the outcome of nucleoplasty. The rational guideline for choosing between the 2 types of surgery is the integrity of the annulus. Key words: disc herniation, nucleoplasty, microdiscectomy, annulus integrity

The review addresses the currently used materials for spinal stabilization surgery by spinal fusion. Among them: autografts; allo-and xenografts; materials of synthetic and biological origin; growth factors; multipotent mesenchymal stromal cells; grafts made by 3D modeling. We discuss advantages and disadvantages of these materials as reported in the literature; with this analysis, we hope to stimulate further research into the graft biocompatibility and biointegration, especially into the issue of reparative regeneration and graft transformation into the bone tissue.

Background: Bone cement leakage during vertebroplasty is a frequently reported complication with the potential for neural injury. Objective: To assess risk factors for epidural cement leakage during vertebroplasty. Setting: Neurosurgical department of a scientific research institute. Study Design: This is a prospective cross-sectional randomized trial. Methods: Seventy-five patients with intractable pain due to low energy vertebral compression fractures between T11 and L5 were treated with vertebroplasty at 150 vertebral levels. Preoperative computed tomography (CT) scans were utilized to characterize vertebral parameters including the type of nutrient foramena in the posterior vertebral cortex. Following vertebroplasty, distance from the needle tracts to the midline and the presence and type of any epidural cement leakage were determined. Using logistic regression analysis, significant risk factors for cement leakage were determined. Results: A smaller distance between the tip of the needle and the midline and a magistral type of venobasillar system were found to be significant risk factors for epidural cement leakage (P < 0.0001). Use of a bipedicular vs. monopedicular technique did not significantly affect the rate of epidural cement leakage (P = 0.3869). Limitations: This study is limited because of the relatively small number of patients and the lack of any patients who had clinical consequences as a result of extensive epidural cement leakage. Conclusion: The type of venobasillar system should be taken into account when planning a vertebroplasty procedure as a magistral type of venobasillar system is associated with the increased rate of epidural cement leakage. It is important to try and achieve a large distance between the needle tip and the midline, especially when a magistral type of venobasillar system is present, to reduce the risk of epidural cement leakage. Key words: Vertebroplasty, intracanal cement leakage, low energy vertebra fracture

Background: Computed tomography (CT) can be used to accurately determine bone density in Hounsfield units (HU), the use of CT as a predictive tool has not been conclusively demonstrated in relation to low energy vertebra compression fracture (VCF).The aim of this study was to define the CT parameters that could be used to predict the risk of VCF. Materials and Methods:One hundred consecutive patients undergoing CT scans were enrolled in this study. Bone density measurements were obtained at the T10-L5 levels from the cancellous portion of the vertebral body in the mid-sagittal, mid-coronal and axial planes. The presence of a single-level or multi-level VCF was identified by CT. Multi-level degenerative changes were characterized and recorded. Logistic regression was utilized to assess the relationship between the variables of bone density in HU, single-or multi-level VCF and the presence of degenerative changes.Results: HU were found to have a strong correlation to the risk of VCF. HU of less than 101 were associated with a significant increase in the rate of VCF, whereas HU of less than 82 were associated with a significant increase in the rate of multilevel VCF. Hypertrophic degenerative changes were found to be associated with a decreased rate of VCF. Conclusion:CT data can accurately define the risk of VCF and therefore presents a useful clinical tool to support the need for prophylactic medical therapies for osteoporosis or to provide information useful in counseling patients at risk for VCF.

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