Spine 16(8 Suppl):S455458, 1991. leg pain. In the remaining patients, the standard construct was three-segment fixation spanning four vertebrae and three discs, two above and one below the fractured vertebra, using six screws. Each side was judged separately. Clinical Orthopaedics and Related Research411:86-94, June 2003. 34. What can spine surgeons do to improve patient care and avoid medical negligence suits? Abstract BACKGROUND CONTEXT Surgeons have increasingly adopted robotic-assisted lumbar spinal fusion due to indications that robotic-assisted surgery can reduce pedicle screw misplacement. 17,18,31,39 Edwards 6 showed that solid arthrodesis developed in 96% of patients without previous surgery, whereas 84% of patients having secondary operations experienced a similar result. The defendants explanation provided an explanation for why Nyquists foot drop did not resolve after the misplaced screw was removed and shed doubt on the plaintiffs theory of liability. Roy-Camille R, Roy-Camille M, Demeulenaere C: Osteosynthese du rachis dorsal, lombaire et lombo-sacre par plaque metalliques vissees dans les pedicules vertebraux et es apophyses articularies. Koktekir E, Ceylan D, Tatarli N, Karabagli H, Recber F, Akdemir G. Spine J. 2005;293(21):26092617. Spine 13:10121018, 1988. Nominal and inflation-adjusted award payouts were higher for trial verdicts than for settlement/arbitration, with a nominal average of $1,140,473 $841,683 versus $788,533 $306,186 awarded to the plaintiff, respectively (p = 0.30). 2 One of the first obstacles regarding . It should be used by experienced and qualified surgeons who are aware of the pitfalls associated with its use. The medical malpractice suit Ayala v. Friedlander, M.D., claimed that a March 2011 lumbar fusion surgery performed by neurosurgeon Marvin Friedlander, MD, and orthopedic spine surgeon Douglas Bradley, MD, strayed from the accepted standards of care because a pedicle screw was placed in the wrong location. The medicolegal impact of misplaced pedicle and lateral mass screws on Thirty-five (27.56%) had IMP and 18 (14.17%) had SAR. Ann R Coll Surg Engl. Pedicle screw insertions are commonly used for posterior fixation to treat various spine disorders. This study quantifies the rate of screw misplacement on a per-patient basis to highlight its effect on potential morbidity. 2022 Dec;31(12):3544-3550. doi: 10.1007/s00586-022-07427-0. The remaining two patients had asymptomatic junctional problems develop after two- and three-segment fusions, at the third and fourth postoperative year, respectively. Study supervision: Goodwin, Karikari, Shaffrey, Abd-El-Barr, KD Than. 2021 Nov 26;22(1):986. doi: 10.1186/s12891-021-04860-y. The majority of screws were misplaced in the lumbar spine for both plaintiff- and defendant-awarded cases (66.7% vs 57.4%, respectively, p = 0.564; Table 1). As part of the surgery, Dr. Taras Masnyk inserted four metal screws into the plaintiffs spine. The initial search using the terms above returned 3654 cases. With pedicle shapes and sizes varying wildly in the scoliotic spine, misplacement of a screwas well as and under- or oversizingare real possibilities in spine surgery. It argued that the foot drop was unavoidable and due to the surgeons need to manipulate the right L5 nerve root in order to remove Nyquists herniated disc during the spinal fusion surgery. Malpractice litigation and the spine: the NHS perspective on 235 successful claims in England. 2017;42(3):177185. 2014;20(2):196203. However, the misplacement of pedicle screws can lead to disastrous complications. Eur Spine J. Spinal fusion procedures are increasingly performed each year, with Deyo et al. + 48 696 042 504. Copyright 1944-2023 American Association of Neurological Surgeons, Copy this link, or click below to email it to a friend. single homes for sale in lehigh valley, pa single homes for sale in lehigh valley, pa Home Realizacje i porady Bez kategorii single homes for sale in lehigh valley, pa FOIA Moreover, local court rulings are not included in the Westlaw Edge database; however, this is unlikely to present meaningful bias given that malpractice claims are generally filed in state courts. Misplacement of Pedicle Screws Leads to Years of Pain and Opioid Addiction Despite this problem, the clinical result was excellent. Some error has occurred while processing your request. Jury Verdict for Doctor for Screw Allegedly Misplaced During Lumbar J Bone Joint Surg 61A:201207, 1979. 2020;11:38. The plaintiff will recover $2.25 million because of a high-low agreement the lawyers entered after closing arguments, the New Jersey Law Journal reports. Fishers exact test and the Mann-Whitney U-test were used for the analysis of categorical and continuous data, respectively, except when an unpaired t-test was utilized for analyses related to normalized, nominal, and inflation-adjusted award totals. Spine arthrodesis was evaluated with plain AP and lateral radiographs taken 1 year after surgery. The last two patients had a T12L1 fracture-dislocation and a L4L5 spondylolytic spondylolisthesis at the site of plug dislodgments. These risks can be minimized by the judicious use of instrumentation by experienced surgeons for specific indications as supported by the literature. None of these complications resulted in additional surgery or in a significant increase of morbidity. General complications were considered those developing during and after surgery that were not directly related to instrumentation. JAMA Intern Med. pedicle screw: A rigid surgical implant used to stabilize adjacent spinal segments in spinal fusion surgery. Wolters Kluwer Health A total of 2396 screws were placed accurately (87.96%). As compared to cases in 19952009, those in 20102019 resulted in a significantly higher average nominal payout to plaintiffs ($776,439 $74,460 vs $1,506,000 $385,527, p = 0.028). Retrospective analysis of reasons and revision strategy for failed thoracolumbar fracture surgery by posterior approach: a series of 31 cases. Am J Otolaryngol. Conversely, Nyquists foot drop did not resolve after the screw was removed, which begged the question of whether the foot drop was in fact caused by the misplaced screw. Todd NV. Pedicle screws have been used to treat spinal disorders, including those caused by spinal cancer, congenital anomalies, trauma, and chronic pain syndromes. 2018;83(5):9971006. J Neurosurg Spine. Pedicle screw placement accuracy using ultra-low radiation imaging with image enhancement versus conventional fluoroscopy in minimally invasive transforaminal lumbar interbody fusion: an internally randomized controlled trial. Rothberg MB, Class J, Bishop TF, et al. Saillant G: Etude anatomique des pedicules vertebraux: Application chirurgicale. Instrumentation removal is an option for patients with successful arthrodesis, but remains controversial. Although the rationale for using pedicle screw fixation is fairly clear, controversy continues regarding the application of pedicle instrumentation for spine arthrodesis, especially on the degenerative lumbar spine. Spine surgery has been disproportionately impacted by medical liability and malpractice litigation, with the majority of claims and payouts related to procedural error. The patient had to undergo a subsequent surgery to remove the pedicles. Study design: Segal J. Plaintiff award amounts were adjusted for inflation as of April 2020 using an online inflation calculator provided by the US Bureau of Labor Statistics (https://www.bls.gov/data/inflation_calculator.htm). However, the medicolegal impact of misplaced screws on spine surgery has not been directly reported in the literature. Each case was then carefully screened for relevance and sufficient data. The rate of reoperation for screw misplacement per screw was 0.17%. A rod is used to hold the vertebra together to allow fusion to occur. Spine (Phila Pa 1976). Two patients with associated injuries in the lower limbs had deep venous thrombosis develop, three patients had pneumonia develop, and four patients with neurologic impairment had urinary tract infections develop. A retrospective review of charts, x-rays (XRs) and computed tomography (CT) scans was performed. PURPOSE This study aimed to compare rates of perioperative complications between robotic-assisted and conventional . shooting in valdosta leaves one dead Medical malpractice litigation has made a significant impact on spine surgery, with many spine surgeons avoiding complex cases or practicing other defensive medicine tactics in an effort to avoid being sued.5 Moreover, the majority of neurosurgeons spend more than 10% of their annual revenue on malpractice insurance,1,14 and the excessive financial risk of litigation is even leading some insurers to no longer offer coverage to spine surgeons.19 A 2011 study in the New England Journal of Medicine found that 19.1% of neurosurgeons are named as a defendant in a malpractice suit each year (highest of any specialty).12 Moreover, 88% of physicians in high-risk specialties, like neurosurgery, are involved in a lawsuit by age 45, increasing to a concerning 99% by 65 years of age.12 Such litigation places a substantial financial, temporal, and emotional burden on physicians in high-risk specialties, with studies showing that up to 72% of neurosurgeons1 admitted that their fear of litigation significantly influenced their practice,25 with many avoiding high-risk patients altogether.1 Similarly, Nahed et al. 20 Tips to Avoid and Handle Problems in the Placement - ScienceDirect Rather, the defense demonstrated that although the misplaced screw had in fact irritated the L4 nerve root for the six days before it was removed, the related symptoms resolved with the screws removal. Int Orthop 20:3542, 1996. EOS System Courtesy of EOS imaging. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. 5. Pedicle screw replacement in spinal surgery - The MDU Li HM, Zhang RJ, Shen CL. Spine 19(20 Suppl):2279S2296, 1994. and 17.1% of the patients included had at least one screw misplaced. 38. The screws were needed to stabilize the spine and fix the fused vertebrae in place. Lumbar Spine Surgery. Moreover, several cases stated that the surgeon used only the anteroposterior or the lateral view, but not both, and the plaintiffs counsel used this information in support of their claim. Pedicle screw fixation is an effective but demanding method to treat various spinal disorders and is associated with a significant complication rate. Comparetto, Esq., 727-328-7900, www.florida-malpractice-lawyers.com. Likewise, research shows that breaches still occur when these tools are used,33,40 and some studies did not find a difference in pedicle breach rates compared to those with traditional fluoroscopic and freehand techniques.33 Ultimately, misplaced instrumentation is a risk of any spinal fusion surgery, and a thorough discussion of these risks, as well as the alternative management options, is essential to maintain high-quality patient care and to avoid litigation. 2012;41(2):6973. Categorical and continuous data are described as frequency (percentage) and median (interquartile range), respectively, except for the use of mean standard deviation for award amounts since both nominal and inflation-adjusted award totals passed (alpha = 0.05) the DAgostino-Pearson omnibus normality test. Neurosurgical practice liability: relative risk by procedure type. George Sapkas, MD, DSc; and Panayiotis J. Papagelopoulis, MD, DScGuest Editors. In two patients in the current series, dislodgement of the rods from tulip screws occurred, as reported originally by Edmunds et al. 1,12,19,22 The largest series of adjacent segment breakdown was reported by Schlegel et al. Conclusion: Submitting a contact form, sending a text message, making a phone call, or leaving a voicemail does not create an attorney-client relationship. Safety and efficacy of pedicle screw placement using intraoperative computed tomography: consecutive series of 1148 pedicle screws. MeSH 26. Although the rate of the reported complications was high, the final outcome of the patients was not affected significantly. The plaintiff underwent revision surgery in May 2013. pedicle screw misplacement malpractice. 2011;24(1):1519. These numbers are in line with the current literature. Dalenberg DD, Asher MA, Robinson RG, Jayaraman G: The effect of a stiff spinal implant and its loosening on bone mineral content in canines. Except for the patient with an infected pseudarthrosis who had a flat back syndrome (sagittal imbalance) develop, coronal imbalance was observed in five patients (4.5%), and ranged from 7.5 to 12 (Fig 3). 0 attorneys agreed. 2013;34(6):699705. A review of medicolegal malpractice suits involving cervical spine: what can we learn or change? J Bone Joint Surg 62A:13021307, 1980. PMC While reported to be one of the best legal research resources available and utilized in several previous studies,7,14,16,23,24 available court documents and clinical/operative details are highly variable and greatly limited among case files. 3). Presse Med 78:14471448, 1970. J Neurosurg Spine. Problems at the junctions of the instrumented spine were seen in five patients (4.5%). 2011;365(7):629636. Clin Orthop 203:4553, 1986. Larson AN, Santos ER, Polly DW Jr, Ledonio CG, Sembrano JN, Mielke CH, Guidera KJ. The intent is to provide relief from pain and nerve damage. Both issues represent the most frequent and highest payouts in spine malpractice claims.10,14,22 While several studies have explored many of the factors related to malpractice claims in spine surgery, the medicolegal impact of misplaced pedicle and/or lateral mass screws has not been directly reported in the literature. All of these patients were asymptomatic and had satisfactory final clinical outcomes (Fig 2). Conception and design: Sankey, KD Than. This demonstrates technical ability but does not represent the impact of screw misplacement on individual patients. We avoid using sharp automated drilling, and probe fully the pedicle cavity to prevent nerve root impairment. Delayed open treatment of aortic penetration by a thoracic pedicle J Pediatr Orthop. Quinnell RC, Stockdale HR: Some experimental observations of the influence of a single lumbar floating fusion on the remaining lumbar spine. Stauffer RN, Coventry MB: Posterolateral lumbar-spine fusion: Analysis of the Mayo clinic series. National Library of Medicine Procedural errors led to combined payouts totaling $124,943,933 in neurosurgery claims between 2003 and 2012 in a study looking at data from the Physician Insurers Association of America Data Sharing Project.10 However, our study is the first to report the direct medicolegal impact of screw misplacement on US spine surgery, with 30.9% of judgments/settlements in favor of the plaintiff, resulting in average payouts of $1,204,422 $753,832 per claim. Plaintiff-awarded cases by US region (left). Misplacement of Pedicle Screws Leads to Years of Pain and Opioid Addiction Nationally Recognized Regionally Dominant Contact Us Now For a Free Consultation Over $850 Million in Verdicts and Settlements Home Articles Misplacement of Pedicle Screws Leads to Years of Pain and Opioid Addiction Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and, Malpractice liability and defensive medicine: a national survey of neurosurgeons, Defensive medicine among high-risk specialist physicians in a volatile malpractice environment, Defensive medicine: a culprit in spiking healthcare costs, Incidence and costs of defensive medicine among orthopedic surgeons in the United States: a national survey study, Defensive medicine in U.S. spine neurosurgery, Personal consequences of malpractice lawsuits on American surgeons. This retrospective study analyzes the complications and the problems developed during and after pedicle screw fixation in patients with spinal disorders and trauma. The patient suffered permanent nerve damage as a result of the puncture. Lumbosacral pedicle screw placement using a fluoroscopic pedicle axis Spine (Phila Pa 1976). It is easier to confuse a jury than convince a judge: the crisis in medical malpractice. Sarwahi V, Ayan S, Amaral T, Wendolowski S, Gecelter R, Lo Y, Thornhill B. Spine Deform. Gertzbein SD, Robbins SE: Accuracy of pedicular screw placement in vivo. From the *Department of Orthopaedic Surgery, University of Crete Medical School, Heraklion, Greece; and the **First Department of Orthopaedics, University of Athens Medical School, Athens, Greece. Mason A, Paulsen R, Babuska JM, et al. Many technological advances have been made over the past several decades in an effort to improve the accuracy of screw placement in spine surgery.3436 For example, 3D fluoroscopybased image guidance has been shown to decrease the pedicle breach rate in several studies compared to the rate with 2D fluoroscopic guidance or the freehand technique, particularly in deformity and revision surgeries.21,34,36,37 CT guidance or intraoperative confirmation has also been shown to further improve the accuracy of pedicle screw placement,3638 with reported accuracy rates of 89%100% reported in the literature, depending on the authors breach criteria.35 However, it is important to note that the use of this technology is often accompanied by a lower threshold for intraoperative screw revision, sometimes leading to higher rates of replaced screws.33 Arguably, these improved trajectories may avoid iatrogenic neurological deficits due to prolonged nerve root compression or even improve the stability of the construct;34,37 however, prospective studies of long-term outcomes and rates of revision surgery remain sparse in the literature. A total of 247 screws (9.07%) were BMP, 52 (1.91%) were IMP, and 29 (1.06%) were considered SAR. Accuracy of pedicle screw insertion by AIRO intraoperative CT in complex spinal deformity assessed by a new classification based on technical complexity of screw insertion. Nottmeier EW, Seemer W, Young PM. St Louis, CV Mosby 322327, 1987. Problems in the instrumented segments were considered those occurring from narrowing of the disc space greater than 3 mm, pseudarthrosis, and loss of reduction. haroinfather roblox id 2013;123(9):20992103. Steffee AD, Brantigan JW: The variable screw placement spinal fixation system: Report of a prospective study of 250 patients enrolled in Food and Drug Administration clinical trials. The third patient, who had central spinal stenosis, was treated by decompression alone. 2007;106(6):11081114. 22. Harrington and Tullos 11 first reported the technique of transpedicle screw fixation, and Roy-Camille et al 23 popularized the first practical method of pedicle screw fixation. Illinois Jury Finds in Favor of Doctor in Gallbladder Surgery that Led to Fatal Bowel Perforation Nickl v. Barry S. Rosen, M.D. Judgment information associated with a defendant (surgeon) versus plaintiff (patient) ruling, trial versus settlement versus arbitration decision, award amount, and time to decision or case closure from index surgery was also recorded. Junctional problems were recorded as pathologic changes of the adjacent motion segments, just above and below the instrumented and fused segments. Defensive medicine: a culprit in spiking healthcare costs. Several studies reveal that fusion rates increase when rigid internal fixation is used, 14,20,21,33,38 and that by using pedicle screws and plates or rods for stabilization, spinal arthrodesis can be limited to the disease segments. Recently, robot-assisted pedicle screw implantation has been increasingly utilized at large-volume academic centers. Five patients had uneventful early postoperative course. 2. Orthop Trans 11:99, 1987. Thus, meaningful efforts to limit the rate of misplaced pedicle and lateral mass screws, such as the routine use of intraoperative imaging confirmation and/or computer- or robot-assisted navigation, should be carefully considered. Defendant-awarded cases by US region (right). [] The accuracy for free-hand screw placement technique varies from 69% to 94%. Waddell G, Kummell EG, Lotto WN, et al: Failed lumbar disc surgery and repeat surgery following industrial injuries. (%), Pseudarthrosis requiring revision surgery. The plaintiff received $2.4 million for pain and suffering and loss of enjoyment of life, $2 million for lost income and approximately $123,000 for medical expenses. Cookie Policy. 14. Of note, while only 38.2% (n = 26) of cases in our study mentioned the use of intraoperative radiographic confirmation, only one of these cases reported that the misplaced screw had been caught prior to leaving the operating room, which had resulted in an inadvertent dural tear and L5 nerve root injury. pedicle screw misplacement malpractice Seven hundred sixty-three screws were inserted in 138 patients. A p < 0.05 was considered statistically significant. Melissa Nyquist required a lumbar back fusion for a herniated disc at the L4-5 level. In their meta-analysis of nine randomized controlled trials, Li et al. 2. Mean amounts awarded SD to plaintiffs by jury trial (n = 13) versus settlement/arbitration (n = 7), adjusted for inflation as of April 2020. We serve the following localities: Cook County including Arlington Heights, Barrington, Berwyn Township, Chicago, Des Plaines, Glenview, Orland Park, Palos Park, Schaumburg, and Tinley Park; DuPage County including Downers Grove, Naperville, and Bolingbrook; Kane County including Aurora, Elgin and Geneva; Lake County including Waukegan; and Will County including Joliet. PDF Intraoperative biomechanics of lumbar pedicle screw loosening following Results: A total of 2724 screws were placed in 127 patients. Results. Furthermore, 25 patients (22.3%) reported persistent pain in the iliac crest (donor graft site) for several months, for which they were treated with repeated lidocaine injections and analgesics. Intraoperative pedicle fractures requiring further points of fixation. Pedicle instrumentation in the thoracolumbar and lumbar spine is a technically challenging procedure. Three slender patients complained of soft tissue irritation and a bothersome prominence because of the screws bulky profile. J Spine Surg. Incidence and costs of defensive medicine among orthopedic surgeons in the United States: a national survey study. Mayo Clinic uses the latest robot-assisted technology when indicated to enhance surgical precision in these procedures. There were two complete degenerations of the upper disc, one central canal stenosis, and two asymptomatic disc space narrowings and retrolistheses. Statistical analysis: Sankey. Cases involving wrong-level or -side surgery, implant malfunction, or other misplaced spinal instrumentation (e.g., interbody cases, rods, surgical instruments, etc.) Spine 15:908912, 1990. Your current browser may not support copying via this button. Katonis PG, Kontakis GM, Loupasis GA, et al: Treatment of unstable thoracolumbar and lumbar spine injuries using Cotrel-Dubousset instrumentation. reported that 69.3% of neurosurgeons who responded to their survey saw every patient as a potential lawsuit.1. 19. Accuracy of fluoroscopically-assisted pedicle screw placement: analysis of 1,218 screws in 198 patients. Please try after some time. The remaining eight patients, including two patients with spinal trauma, five patients with infection, and one patient with a tumor, had anterior and posterior procedures. Pullout strength of misplaced pedicle screws in the thoracic and lumbar Unilateral nonunion was seen in three patients (2.7%), associated with implant failure in one of the patients. A total of 2724 screws were placed in 127 patients. Both of these patients complained of thigh pain but refused any additional surgery. Bydon M, Xu R, Amin AG, Macki M, Kaloostian P, Sciubba DM, Wolinsky JP, Bydon A, Gokaslan ZL, Witham TF. South Med J 62:17, 1969. First, this is a retrospective analysis of cases obtained from the web-based Westlaw Edge legal research database. 144 Whitecloud III TS, Butler JC, Cohen JL, Candelora PD: Complications with the variable spinal plating system. Accuracy of C2 pedicle screw placement using the anatomic freehand technique. Pedicle screw accuracy in thoracolumbar fractures- is routine postoperative CT scan necessary? The rate of misplaced pedicle screws ranges from 1.1% to 28.8%, 10 although neurologic injury from misdirected pedicle screws has been reported to occur in 0% to 12% of patients. The accuracy of pedicle screw placement using intraoperative image guidance systems. 31. J Bone Joint Surg 73A:11791184, 1991. Except for two patients with spinal metastatic disease, all other patients received an iliac crest autologous bone grafts. 4). Dr. Shaffrey has received grants from the NIH and Department of Defense. The most frequent primary injury listed for a lawsuit was nerve root injury, present in 81.0% (n = 17) and 74.5% (n = 35) of plaintiff- and defendant-awarded cases, respectively (p = 0.7). 15. They both had motor deficits from which 1 patient recovered completely. 2018;18(2):209215. Luque ER: Segmental spinal instrumentation of lumbar spine. Would you like email updates of new search results? A total of 2396 screws were placed accurately (87.96%). Screws were divided into four categories: screws at risk (SAR), indeterminate misplacements (IMP), benign misplacements (BMP), accurately placed (AP). 2012;89(10):7071. In addition, hardware failures were observed in 12 patients (10.7%), junctional problems were seen in five patients (4.5%), problems in the instrumented segments were seen in 39 patients (34.7%), and problems of balance occurred in five patients (4.5%). The medicolegal landscape of spine surgery: how do surgeons fare? Clin Orthop 203:126134, 1986. Disc space narrowing was the most common problem after instrumented arthrodesis and was observed in 27 patients (24.1%). One hundred four of the 112 patients had a posterior procedure. Problems of balance were coronal (scoliosis greater than 5 or trunk shift greater than 5 mm) as seen on the AP radiograph taken with the patient standing or sagittal (failure to obtain or maintain lumbar lordosis). ABSTRACT: Pedicle screw loosening has been implicated in recurrent back pain after lumbar spinal fusion, but the degree of loosening has not been systematically quantied in patients. Nyquist had requested the defendants offer, which in retrospect was perhaps a poor decision in light of the Kane County jurys verdict. Start; O firmie; Usugi; Serwis; Realizacje i porady; Kontakt 3. Error in trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. Laryngoscope. Defensive medicine in neurosurgery: the Canadian experience. Accuracy of pedicle screw placement and clinical outcomes of robot-assisted technique versus conventional freehand technique in spine surgery from nine randomized controlled trials: a meta-analysis. L3S1 spine arthrodesis was done in the first patient but the correction of scoliosis was not sufficient and coronal imbalance persisted after surgery, which accelerated the degeneration of the level just above the arthrodesis. 16,24,28 Simultaneously, the evolution of the surgical techniques has led to increased procedural safety. The development of the transpedicle screw has provided control of the vertebral motion segment in each plane, resisting any type of load. 2020;162(6):13791387. Grubb SA, Lipscomb HJ: Results of lumbosacral fusion for degenerative disc disease with and without instrumentation: Two- to five-year follow-up. Dr. Abd-El-Barr is a consultant for Spineology. Johnston II CE, Ashman RB, Baird AM, Allard RN: Effect of spinal construct stiffness on early fusion mass incorporation: Experimental study. . Rajasekaran S, Bhushan M, Aiyer S, et al. In our opinion, these problems may be prevented by applying the following principles: limitation of spine arthrodesis to the pathologic levels, inclusion of already extensive changes at the level above or below the planned arthrodesis into the arthrodesis, restoration of postoperative sagittal and coronal alignment, and avoidance of impingement syndrome from the adjacent nonfused facets. Of the 112 patients, 57 patients had a lumbar degenerative disorder, (lumbar degenerative spinal canal stenosis in 23 patients, degenerative or spondylolytic spondylolisthesis in 12 patients, postlaminectomy instability or stenosis in 20 patients, and recurrent disc prolapse in two patients), 42 patients had spinal cord injury, eight patients had infection, and five patients had a spinal tumor (Table 1).
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