Computer assistance can decrease the incidence of incorrectly positioned pedicle screws.

No abstract

Stand-alone ALIF leads to better clinical results than APLF, without differences in fusion rates after 41 months. Therefore, when a posterior approach is not needed for decompression or reposition, we suggest performing a stand-alone ALIF in cases with single-level DDD.

Progression of degeneration is often described in patients with initially degenerated segment adjacent to fusion (iASD) at the time of surgery. The aim of the present study was to compare dynamic fixation of a clinically asymptomatic iASD, with circumferential lumbar fusion alone. 60 patients with symptomatic degeneration of L5/S1 or L4/L5 (Modic ≥ 2°) and asymptomatic iASD (Modic = 1°, confirmed by discography) were divided into two groups. 30 patients were treated with circumferential single-level fusion (SLF). In dynamic fixation transition (DFT) patients, additional posterior dynamic fixation of iASD was performed. Preoperatively, at 12 months, and at a mean follow-up of 76.4 (60-91) months, radiological (MRI, X-ray) and clinical (ODI, VAS, satisfaction) evaluations assessed fusion, progression of adjacent segment degeneration (PASD), radiologically adverse events, functional outcome, and pain. At final follow-up, two non-fusions were observed in both groups. 6 SLF patients and 1 DFT patient presented a PASD. In two DFT patients, a PASD occurred in the segment superior to the dynamic fixation, and in one DFT patient, a fusion of the dynamically fixated segment was observed. 4 DFT patients presented radiological implant failure. While no differences in clinical scores were observed between groups, improvement from pre-operative conditions was significant (all p < 0.001). Clinical scores were equal in patients with PASD and/or radiologically adverse events. We do not recommend dynamically fixating the adjacent segment in patients with clinically asymptomatic iASD. The lower number of PASD with dynamic fixation was accompanied by a high number of implant failures and a shift of PASD to the superior segment.

We conclude that PCEA with ropivacaine and sufentanil, using intraoperatively placed epidural catheters, provides superior analgesia and higher patient satisfaction when compared with PCIA after spinal fusion surgery.

The current gold standard in lumbar fusion consists of transpedicular fixation in combination with an interbody interponate of autologous bone from iliac crest.

Epidural analgesia affects the immune system. Postoperative epidural analgesia, compared with conventional IV opioid therapy, preserves lymphocyte rather than monocyte functions. An improvement of postoperative immune function by epidural analgesia therefore may improve postoperative resistance to infectious complications or to chronic pain states.

Different strategies exist to treat intervertebral disc degeneration. Biological attempts to regenerate the disc are promising. However, degeneration of the disc is always accompanied by alterations of disc height, intradiscal pressure, load distribution, and motion patterns, respectively. Since those preconditions are independent factors for disc degeneration, it is unlikely that regeneration may occur without firstly restoring the physiological status of the affected spinal segment. In vitro and in vivo animal studies demonstrate that disc distraction normalizes intradiscal height and pressure. Furthermore, histological and radiological examinations provided some evidence for regenerative processes in the disc. Only dynamic stabilization systems currently offer the potential of a mechanical approach to intervertebral disc regeneration. Dynamic stabilization systems either using pedicle screws or with an interspinous device, demonstrate restabilization of spinal segments and reduction of intradiscal pressure. Clinical reports of patients with degenerative disc disease who underwent dynamic stabilization are promising. However, there is no evidence that those implants will lead to disc regeneration. Future treatment concepts should combine intradiscal cell based therapy together with dynamic restoration of the affected spinal segment.