Session 16: Spine

18. November
09:00 - 10:00
Lokale: Vingsal 3
Chair: Ane Simony and Søren O. Nissen

121. Stand-alone ALIF versus TLIF in patients with low back pain – a propensity matched cohort study with two-year follow-up
Ali A. Toma 1, Dennis W. Hallager 1, Peter Udby 1+2, Rune D. Bech 1, Mikkel Ø. Andersen 2, Leah Y. Carreon 2
Spine Unit, Department of Orthopedic Surgery, Zealand University Hospital, Køge, Denmark 1 Center for Spine Surgery and Research, Spine Center of Southern Denmark—part of Lillebaelt Hospital, Middelfart, Denmark 2

Background: Instrumented lumbar fusion performed by an anterior or a transforaminal approach has theoretically different advantages and disadvantages. Few studies have compared Patient Reported Outcomes (PROs) between stand alone anterior lumbar interbody fusion (ALIF) and transforaminal lumbar interbody fusion (TLIF)
Aim: The aim of the study was to compare Patient Reported Outcomes (PROs) at two-year follow-up after ALIF and TLIF in patients with degenerative spine conditions.
Materials and Methods: We performed a dual-center registry-based cohort study over a nine-year period (2010-19) on patients with degenerative spine condition undergoing single-level L5/S1fusion surgery, with ALIF or TLIF registered in the Danish National spine-registry (DaneSpine). Prospective data was collected preoperatively and at one and two-year follow-up. Propensity score matching was performed. Primary outcomes were Oswestry Disability Index ODI, visual analog scale (VAS) and quality of life (QoL) measured by European Quality of Life-5 Dimensions (EQ-5D) index score. Patient satisfaction was measured as secondary outcome. Data are mean±SD.
Results: A total of 92 patients were matched, 46 ALIF and 46 TLIF. Both groups obtained statistically significant improvement in the ODI. At two years ALIF reported improvement from 45±15 to 30±19 (-15(95%CI:-20;-10) and TLIF 46±19 to 36±23 (-10(95%CI:-16;-5). No significant difference was observed between the two groups in change from baseline (DC): -5(95%CI -12;2). We found improvement in QoL at two years compared to baseline but no statistically significant differences in EQ-5D score between the groups (ALIF:0.65±0.35vs.TLIF:0.59±0.26, DC 0,01(95%CI:-0.12;0.12)). VAS score for leg pain (40±31vs.39±33, DC 3(95%CI:-11;17) and back pain (45±31vs.50±28, DC -6(95%CI: -19;7)) at two years shows no significant difference between the two groups. At two years 58% ALIFs vs. 49% TLIFs stated that they are generally satisfied with the treatment, while 18% vs 27% were dissatisfied.
Interpretation / Conclusion: Patients treated with ALIF and TLIF had significant mean improvements in ODI, back and leg pain and EQ5D index score at two years compared to baseline. We found no significant differences in improvement between the groups.

122. The effectiveness of antibiotic in treating patients with chronic low back pain and Modic changes: A systematic review.
Peter Muhareb Udby, Arnold YL Wong, Dino Samartzis
Spine Unit, Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark & Spine Surgery and Research, Spine Center of Southern Denmark - part of Lillebaelt Hospital, Odense, Denmark; Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong SAR, China; Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, USA

Background: Chronic low back pain (CLBP) affects millions worldwide. Despite the high prevalence, many treatments for CLBP only display small-to- moderate effects on pain and disability. Some magnetic resonance imaging studies identify a subgroup of patients with CLBP who demonstrate Modic changes (MCs) extending from the endplate. It is hypothesized that MCs are related to low-grade discitis caused by hematogenic transmission of Cutibacterium acnes to the adjacent damaged lumbar disc.
Aim: This systematic review aimed to summarize evidence regarding the effectiveness of oral antibiotic intervention for CLBP.
Materials and Methods: Five databases were searched. Randomized controlled trials (RCTs) or non-RCTs that investigated the effectiveness of oral antibiotics in treating patients with CLBP were eligible for inclusion. Studies were independently evaluated using the Version 2 of the Cochrane risk-of-bias tool for randomized trials, and the Risk Of Bias In Non- randomised Studies of Interventions, respectively. The strength of evidence for the treatment effectiveness was appraised by GRADE.
Results: A total of 148 potential articles were identified. Four RCT articles and four case series were included. Moderate-quality evidence supported that Amoxicillin-clavulanate or Amoxicillin was significantly better than placebo in reducing Roland Morris Disability Questionnaire in patients with CLBP at the 1-year follow-up. Low- quality evidence from an RCT substantiated that Amoxicillin was significantly superior to placebo in improving Oswestry Disability Index scores at 1-year follow-up. Very low-quality evidence from non-RCTs suggested that three months of oral Amoxicillin-clavulanate significantly improved LBP and leg pain intensity, number of days with LBP, and LBP-related disability. Patients receiving oral antibiotics also reported significantly more adverse effects.
Interpretation / Conclusion: While low to moderate-quality evidence supports that oral Amoxicillin-clavulanate or Amoxicillin is better than placebo in reducing LBP-related disability in a subgroup of patients with CLBP and concomitant type 1 MC, it remains uncertain whether oral antibiotics can yield clinically meaningful improvements in patients with CLBP.

123. Subtherapeutic perioperative Cefuroxime concentrations inside cannulated pedicle screw commonly used in spine surgery – Results from an experimental animal study
Magnus A. Hvistendahl ¹ ², Pelle Hanberg ¹ ², Maiken Stilling ¹ ² ³, Kristian Høy ¹ ² ³, Mats Bue ¹ ² ³
Department of Clinical Medicine, Aarhus University, Denmark¹; Aarhus Denmark Microdialysis Research (ADMIRE), Orthopedic Research Laboratory, Aarhus University Hospital, Denmark²; Department of Orthopedic Surgery, Aarhus University Hospital, Denmark³

Background: Despite minimal invasive surgical spine techniques, postoperative implant associated vertebral osteomyelitis remains a risk of great morbidity for the patient. Perioperative antibiotic prophylaxis is an important preventive measure and local tissue concentration can be quantified with microdialysis. Insertion of spinal implants induce tissue trauma and inflammation, which may affect the proximate implant concentrations of antibiotics.
Aim: We compared perioperative cefuroxime concentrations inside a cannulated pedicle screw to the adjacent non-instrumented vertebral pedicle of the same lumbar vertebra.
Materials and Methods: Microdialysis catheters were placed inside a cannulated pedicle screw commonly used in minimal invasive spine surgery and the adjacent non-instrumented vertebral pedicle of the same vertebra (L1) in 8 female pigs through a surgical posterior open lumbar approach. Following a single-dose intravenous cefuroxime administration (1.5 g), microdialysates and plasma were dynamically sampled over 8 hours. The primary endpoint was the time above cefuroxime clinical breakpoint minimal inhibitory concentration for Staphylococcus aureus of 4 µg/mL (T>MIC4).
Results: T>MIC4 (95% CI) was 123 min (110-136) in plasma, 0 min (-13-13) inside the cannulated pedicle screw and 101 min (88- 114) in adjacent the non-instrumented vertebral pedicle.
Interpretation / Conclusion: A single-dose intravenous cefuroxime administration provided subtherapeutic concentrations for prevention of infection inside a cannulated pedicle screw in the lumbar spine. Sufficient concentrations were achieved in the adjacent non-instrumented vertebral pedicle for up to 1.5-2 hours. Therefore, alternative dosing regimens seems relevant in minimal invasive spine surgery lasting longer than 1.5 hours and additional prophylactic strategies should be considered in high-risk patients.

124. Curve progression in idiopathic scoliosis – 40-year follow-up from diagnosis
Casper Dragsted, Ragborg Lærke, Ohrt-Nissen Søren, Andersen Thomas, Gehrchen Martin, Dahl Benny
Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet and University of Copenhagen

Background: Treatment of idiopathic scoliosis in childhood is mainly guided by curve size and aims to prevent curve progression and long term effects of larger deformities. It is generally accepted that curves >50° will progress throughout adulthood, but less well described what happens with mild to moderate curves after the end of observation or non-surgical treatment.
Aim: The purpose was to asses long-term curve progression in non-operated patients with idiopathic scoliosis and compare curve progression in thoracolumbar and lumbar (TL/L) curves with thoracic curves.
Materials and Methods: We identified 177 patients diagnosed with a pediatric spinal deformity and treated at our institution from 1972 through 1983. 104 of all eligible patients completed follow-up (69%), 91 of these were diagnosed with juvenile (n=5) or adolescent idiopathic scoliosis (n=65). We excluded patients with infantile, neuromuscular, syndromic and congenital scoliosis. Patient files from childhood were reviewed including detailed descriptions of main curve, type and magnitude from diagnosis to end of treatment/observation at skeletal maturity. Patients were examined with long standing full spine radiographs.
Results: Mean follow-up was 40.8(2.6) years and 86/91 patients (95%) were female. 18 patients underwent Harrington rod instrumentation in adolescence and additional 3 patients underwent surgery later in adulthood leaving 70 patients for analysis of curve progression, 43 (61%) of them had been treated with a Boston brace. For curves <30° at skeletal maturity (n=32), mean curve progression was 10° (SD 12, range -5 to 44); for curves 30-50° (n=28) mean progression was 19° (SD 12, range -3 to 49); and for curves >50° (n=7) mean progression was 17° (SD 6, range 10-25). This corresponds to a curve progression of 0.3°/year, 0.5°/year and 0.4°/year, respectively. For curves 30- 50° we found a greater curve progression for TL/L curves (mean 22°) than for thoracic curves (mean 17°), but this was not statistically significant [95%CI for mean diff: -17 to 2].
Interpretation / Conclusion: We found substantial curve progression for curves 30-50° at skeletal maturity comparable to curves >50° and curve progression tends to be larger for TL/L than for thoracic main curves.

125. The effect of Risser stage on the risk of curve progression in patients with adolescent idiopathic scoliosis treated with night-time bracing
Martin Heegaard, Søren Ohrt-Nissen, Niklas Tøndevold, Benny Dahl, Thomas B Andersen, Martin Gehrchen
Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark

Background: Risser stage is widely used as a marker for skeletal maturity (SM) and thereby an indirect measure for the risk of progression of AIS. The SRS recommendations for bracing Risser stage 0-2 as Risser stage 3 or above is considered low-risk. Very few studies have assessed the risk of progression in Risser 3-4.
Aim: To determine if Risser stages 3-4 provide a meaningful cut-off in terms of progression risk in patients with adolescent idiopathic scoliosis (AIS) treated with night-time bracing.
Materials and Methods: AIS patients treated with night-time brace from 2005 to 2018 with a Cobb angle between 25-40 degrees and Risser 0-4 were included. We recorded age and menarche status at initiation of treatment. Curve progression (>5 degrees increase) was monitored until surgery or SM.
Results: One hundred thirty-five patients were included (Risser 0-2: n=86, 3-4: n=49). Radiographic progression occurred in 52% and 35% had progression beyond 45 degrees. Twenty-six percent of the patients underwent fusion surgery at SM and additionally 8% more underwent fusion surgery within 2 years after SM. Progression rate in the Risser 0-2 group was 60% and 38% in the Risser 3-4 group (p=0.013). Univariate logistic regression analysis of progression showed statistically significance in Risser group (OR: 0.38, 95%CI: 0.18-0.78), pre- menarche status (OR: 0.23, 95%CI: 0.10-0.51) and age (OR: 0.63, 95%CI 0.47-0.84). However, in multivariate logistic regression analysis only premenarchal status showed a statistically significant association (OR: 0.37, 95%CI: 0.15- 0.93).
Interpretation / Conclusion: Risser stage does not provide a clinically meaningful differentiation of progression risk as the progression rate was high in the Risser 3-4 group. Risk assessment should likely include multiple SM factors such as age and menarche status. Additionally, other skeletal markers, such as hand, wrist and proximal humerus radiographs, should also be considered.

126. Health Related Quality of Life in patients with Idiopathic Scoliosis 40 years after diagnosis
Laerke Ragborg, Casper Dragsted, Søren Ohrt-Nissen, Thomas Andersen, Martin Gehrchen, Benny Dahl
Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University of Copenhagen, Denmark

Background: Few studies have investigated the very long-term Health Related Quality of Life (HRQoL)in patients with idiopathic scoliosis. It has been suggested that patients with Thoracolumbar or Lumbar TL/L scoliosis suffers from increased disability compared with thoracic scoliosis (Th)
Aim: To investigate if patients with TL/L have lower HRQoL at long-term follow-up compared with patients with Th curves . Moreover, that HRQoL reflects the severity of the scoliosis
Materials and Methods: Full medical records including radiograph descriptions from patients referred to our institution between 1972 and 1982 for a pediatric scoliosis were reviewed. In total, 177 were identified and of all eligible patients, 104 (69%) participated in the study. Of these, 91 had Juvenile (n=5) or Adolescent Idiopathic Scoliosis (n=86). Patients were followed-up with full-spine radiographs and HRQoL questionnaires (SRS- 22r). We analyzed HRQoL for patients with no treatment (n=27), bracing (n=46) and surgical treatment (n=18), respectively, and compared outcomes between Th and TL/L curves
Results: Mean follow-up time was 40.8±2.6 years, and the mean age at follow-up was 54±2.7 years. Eighty- six (95%) were female, and 51(53%) had a main thoracic curve. Main Cobb angle was significantly larger for Th curves compared with TL/L at end of treatment/observation, 36 ±14° and 29± 14° respectively (p=0.02), and larger at follow-up 51±17° and 38±21° (p=0.003). We found a SRS22r Subscore=3.9 (95% CI; 3.7-3.9) in our cohort, which is lower compared to an age-matched population SRS-22r Subscore= 4.4 (95 % CI; 4.2-4.5). We did not find any difference in SRS-22r Subscore between TL/L 3.8±0.7 and Th curves 4±0.7 (p=0.2). There was no difference in SRS22r Subscore between treatment groups; no treatment 4.1±0.7, bracing 3.8±0.7 and surgery 3.8±0.7 (p=0.2). We found a significantly lower Self-image score for braced 3.5±0.7 and surgically treated 3.6±0.8 patients compared with no treatment 4.0±0.9, but no difference was found between the treatment groups for the remaining subdomains
Interpretation / Conclusion: We found no difference in SRS22r subscores between TL/L and Th scoliosis despite differences in curve size. Moreover, overall HRQoL was not related to treatment in adolescence

127. MRI Proxies for Segmental Instability in Degenerative Lumbar Spondylolisthesis Patients
Signe Forbech Elmose¹, Mikkel Østerheden Andersen¹, Freyr Gauti Sigmundsson², Leah Yacat Carreon¹
Center for Spine Surgery and Research, Spine Center of Southern Denmark, Lillebaelt Hospital, Oestre Hougvej 55, DK-5500 Middelfart¹; Department of Orthopaedic surgery, Örebro University Hospital, Södra Grev Rosengatan, SE-70185 Örebro²

Background: Patients with lumbar degenerative spondylolisthesis (LDS) occasionally have a dynamic component of segmental instability. Studies have shown that Magnetic Resonance Imaging (MRI) can indicate instability.
Aim: To investigate whether findings on MRI can be proxies (MRI proxies, MRIPs) for segmental instability in patients with degenerative lumbar spinal stenosis (LSS) and/or LDS.
Materials and Methods: Retrospective cohort study on patients with LSS or LDS at L4/L5 undergoing decompressive surgery +/- fusion from 2010-17 at Middelfart Hospital. Patients divided into two groups according to presence of instability; defined as radiographic slip of >3mm. Outcome measures: Radiograph: sagittal slip (mm). MRIPs for instability: sagittal slip >3mm, facet joint angle (FJA,?), facet joint effusion (mm), disc height index (DHI, %) and vacuum phenomena. Thresholds for MRIPs were determined by Receiver Operating Characteristic (ROC) curves and area under the curve (AUC). Logistic regression to investigate association between instability and MRIPs.
Results: 232 patients: 47 Stable group and 185 Unstable group. The two groups were comparable with regard to baseline Patient Reported Outcome Measures. Thresholds for MRIPs: bilateral FJA =46? (AUC: 0.6, 95%CI:0.6-0.7), bilateral facet effusion =1.5mm (AUC: 0.6, 95%CI:0.5-0.7) and DHI =13% (AUC: 0.6, 95%CI:0.5-0.7). Logistic regression showed statistically significant association between instability and >3mm slip on MRI (OR:221.5, 95%CI(37.4-1311.5), p<0.001), bilateral FJA =46? (OR:5.6, 95%CI(1.9-16.1), p=0.002), bilateral facet effusion =1.5mm (OR:4.5, 95%CI(1.5-13.7), p=0.009) and DHI =13% (OR:9.1, 95%CI(1.8-46.0), p=0.007). ROC curve AUC: 0.95. By absence of MRI slip logistic regression showed statistically significant association between instability and remaining MRIPs: bilateral FJA =46? (OR:3.1, 95%CI(1.3-7.3), p=0.008), facet effusion =1.5mm (OR:2.4, 95%CI(1.2-4.9), p=0.017) and DHI = 13% (OR:12.7, 95%CI(1.7-96.1), p=0.014). ROC curve AUC: 0.76.
Interpretation / Conclusion: Presence of MRIPs showed excellent ability to predict instability on standing radiograph. Even in the absence of slip on MRI the MRIPs had a good ability to predict presence of instability.