A Novel Posterior Spinal Fusion Technology with Local Bone for a Degenerative Spine: A Preliminary Report of 48 Cases

A Novel Posterior Spinal Fusion Technology with Local Bone for a Degenerative Spine: A Preliminary Report of 48 Cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article A Novel Posterior Spinal Fusion Technology with Local Bone for a Degenerative Spine: A Preliminary Report of 48 Cases Chun yang Xi, chi hui, Wenxiao XU, Guang xi Wang, Peng yu Kong, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-286003/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: There were lower rate of solid bony union in the traditional posterolateral lumbar fusion. And previous studies have showed that paraspinal musculature provided predominant vascular ingrowth into the fusion mass. The purpose of this study was to introduce a novel posterior fusion technique which utilized orthotopic paraspinal muscle-pediculated bone flaps for increasing blood supply and accelerating the healing of local bone grafts. In addition, the feasibility, safety, and early outcome of this method were evaluated. Methods: 48 patients of degenerative lumbar disorders were treated with the novel posterior lumbar fusion method. To analyze early complications, rate of fusion and clinical outcome. The fusion status was assessed by three-dimensional reconstruction of CT at at 6 months and 1 year after surgery. The VAS, ODI and SF-36 were assessed pre- and postoperatively. Results: All the patients were followed up for 2 years at least. No operative or postoperative complications were encountered. There was significant statistical difference in VAS, ODI and SF-36 before and after operation (P<0.01). Satisfactory fusion was observed at 6-months follow-up. There was only one case not formed solid fusion at the last follow-up. Conclusions: The posterior lumbar fusion method was such a novel and useful technique that made the position of bone graft more precise and stable that it can increase the fusion rate. This method has decreased the incidence rate of pseudarthrosis, and could get satisfactory clinical outcomes. Orthopedics Lumbar fusion Muscle-pediculated bone flaps Local bone Paraspinal muscle Degenerative diseases Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction It is considered that lumbar spine fusion is a primary procedure for patients with degenerative spinal disorders to maintain spinal stability and prevent postoperative instability. 1 Though some kinds of lumbar fusion techniques have exist, posterolateral lumbar fusion (PLF) is always considered to be the gold standard for lumbar spinal fusion. 2 Although anterior interbody fusion techniques have been developed and continue to be evolved, the traditional technique of posterolateral fusion is still the most commonly performed type of fusion in the lumbar spine. 3 The lower complication rate, lesser surgical blood loss, shorter operative time, and lesser cost associated with this technique as compared with an interbody procedure make this an attractive option to treat spinal disease. 4 Unfortunately, solid fusion is not always acquired. Documented nonunion rates range from 10–40% for posterolateral lumbar fusion, 5 despite the extensive use of internal fixation in the clinical setting. Failure of fusion usually brings a number of troubles to patients and surgeons. Thereby, it is necessary to adopt several measures to reduce or eliminate the incidence of nonunion. Recently, many researches are focused on biological substances of fusion by the addition of BMPs, demineralized bone matrix, and osteoprogenitor cells to the bone graft. 6 – 8 However, many researchers have been concerns about the complications such as airway edema, seroma formation, soft tissue swelling, retrograde ejaculation, carcinogenicity, bone osteolysis and ectopic bone formation. 9 , 10 So these complications affect their extensive application. Many areas can provide a blood supply for bone graft area, such as local bone and muscle tissue. Smucker 11 and Walsh 12 et al studied posterolateral transverse processes fusion in a rabbit model. They revealed that the fusion firstly took place at decorticated transverse processes. This suggested that local decorticated bone may offer a key vascular supply for fusion masses. However, Bawa 13 et al investigated the contribution of paraspinal musculature to posterolateral fusion masses in a rabbit model. They considered that the paraspinal musculature provided crucial vascular ingrowth into the fusion site. The blood supply from local decorticated bone and muscle tissue were equally important for spine fusion, but little attention was paid to the role of muscle tissue. Presently, there were no a posterior arthrodesis that could simultaneouly use the blood supply from local decorticated bone and muscle tissue. For this reason, authors of this study designed a novel posterior lumbar spine arthrodesis with paraspinal Muscle-pediculated bone grafts, and hoped to provide a spinal fusion method with generally application, high union rate and minor paraspinal soft tissue injury. We have proved the advantage in bone formation rate and quality of the novel method by animal experiment. 14 And we have applied the novel bone graft method to clinical patients. So we evaluated the initial clinical result. Materials And Methods A total of 48 consecutive cases, operated during 2011 and 2014 by the senior author for degenerative spinal disorders, were reviewed. One spinal surgical team treated all enrolled patients, and all patients were operated by the same surgeon. Before surgery, patients underwent dual-energy x-ray absorptiometry to assess bone mineral density. All participants met the following inclusion criteria: (1) failure of conservative treatment after a minimum of 6 months; (2) age, 65 years or less; (3) undergoing lumbar fusion surgery at a single level(L4-5); and (4) a follow-up period of 2 years or more after surgery. Exclusion criteria were as follows: (1) Severe osteoporosis; (2) Patients who have had lumbar surgery; (3) abnormal muscle activity or ambulation due to neuromuscular disease; and (4) unable to accurately complete the pre- and postoperative questionnaires due to certain problems such as a stroke or dementia. Surgical Technique Using standard aseptic techniques, a midline skin incision was made from levels of L4–L5. Paraspinal muscles were stripped subperiosteally from the spinous processes and laminae until superior articular processes (SAPs) were seen. After C-arm examining for determining the segment, pedicle screws were inserted to L4 and L5, bilateral decompression by fenestration at the level of L4-5. The bilateral outer margin of SAPs of L5 and outer margin of pars interarticulares (PIs) and inferior border accessory process of L4 were lengthways split by sharp osteotome. Blunt dissection was used to separate the split bone flaps and the adherent longissimus and multifidus muscles to form cuboid bed of bone graft that four walls next to fresh sclerotin. Autologous corticocancellous from decompression by fenestration was cleaned, trimmed, and morselized with a rongeur and placed over the graft bed. Suitable length titanium rods were placed over the graft bed and were used to connect pedicle screws. Screwed up the screw cap, and placed drainage tube. The wound was closed in a standard manner. (Figure 1 ) Radiographic Assessment Radiologic outcome was assessed independently by three orthopedic surgeons, and the radiographic fusion rate was calculated at each time-period by averaging the results of the three observers. Plain anteroposterior were presented before and 3, 6, 12 months after surgery, and at the last follow-up, and were used to evaluate the position of internal fixation. Because of the occlusion of internal fixation, the fusion status was assessed by three-dimensional reconstruction of CT at at 6 months and 1 year after surgery. Sequential bony bridges formed in coronal Plane and sagittal plane between intertransverses or SAPs was considered as solid fusion. CT scans were graded according to the method of Glassman. 1 5 CT scans were graded as demonstrating no fusion (grade 1), partial or limited unilateral fusion (grade 2), partial or limited bilateral fusion (grade 3), solid unilateral fusion (grade 4), or solid bilateral fusion (grade 5). Clinical evaluation Postoperative follow-up was performed at 3 months, 6 months, 12 months and the last follow-up. Preoperative baseline and postoperative outcome measures at 6months, 12 months and the last follow-up included Visual Analogue Scale (VAS,range 0–10) for back and leg pain, the Oswestry Disability Index (ODI) and the Short Form-36 (SF-36). The mean score (range: 0, normal to 5, impossible) for each of the 10 ODI items was determined separately. Analysis of the item related to sex life was not included owing to the small number of respondents. Thus, scores ranged from 0 to 45. Statistical analysis Statistical analysis was performed using the SPSS 22.0 software package. The VAS ODI, and SF-36 scores were analyzed by Kruskal-Wallis one-way analysis of variance (ANOVA). The fusion results were compared statistically using McNemar’s χ 2 test. Significance was defined by P values < 0.05. Results Patient Characteristics The patient cohort included 22 men and 26 women, with an average age of 60.3±11.7 years (range, 37–65 years). All the cases had decompression by fenestration and novel posterior lumbar fusion with pedicle screw instrumentation. The diagnosis included degenerative spinal stenosis in 15 (31.3%), degenerative spondylolisthesis with stenosis in 28 (58.3%), spondylolisthesis with disc degeneration in 5 (10.4%). Fusion was performed at level of L4-5. Minimum follow-up was 28 months (mean, 39.4 months; range, 28-51 months). Typical case images are shown in Figure 2. Operation data All patients successfully completed the operation without iatrogenic nerve injury. The surgical time was 1.85±0.4 hours and the estimated blood loss was 158.6±18.3mL. The drainage tubes were pulled out 48-72 hours after operation, and the patients got out of bed with brace 3 days after surgery. Radiological evaluation The plain anteroposterior showed that loosening and breakage of internal fixation were not take place at the last follow-up. (Figure 3) At 6 months after surgery, the results from the three-dimensional reconstruction of CT displayed that solid fusion was observed in 44 of 48 (91.7%) segments, and the unilateral fusion was showed in 3 of 44 (6.8%) segments. At 1 year after surgery, the results from the three-dimensional reconstruction of CT displayed that solid fusion was observed in 46 of 48 (95.8%) segments, and the unilateral fusion was showed in 2 of 46 (4.3%) segments. There was no significant difference in fusion rate between 6 months and 1 year after operation(P>0.05). Mean fusion grade (scale 1–5) was 4.71 at 6 months after surgery and 4.77 at 1-year after surgery (Table 1). Typical CT images after operation are shown in Figure 4 and Figure 5. Clinical Score At every postoperative interval, statistically significant improvement from baseline was observed for VAS back and leg pain scores(P<0.01). However, VAS back pain score seems to maintain a better score. (Table 2) Statistically significant improvement was also seen for ODI, SF-36(PCS) and SF-36(MCS)(P<0.01). All the postoperative scores except SF-36 (MCS) were the best at 6 months postoperatively compard with the other time nodes. And there was little change in SF-36 (MCS) score at three time points after operation. Discussion Failure or delay in spinal arthrodesis can result in contumacious low back pain, which bring about tremendous pain to patients, and usually need the second operation. Successful spinal fusion requires a suitable local environment that has sufficient surface area of decorticated host bone, adequate graft material, absence of excessive motion, and a rich vascular supply. 16 In a rabbit’s posterolateral intertransverse process fusion model, Smucker 11 et al found neovascularization derived mainly from the decorticated transverse processes, and healing initially occurred near the transverse processes and delayed in the central site. So they considered that the main reason of nonunion might be the fusion mass delay in vascularization of the central region. Bawa 13 presumed that the muscle helped fasten attach the graft to the local bone, but sometimes its interposition may lead to a fibrous cleft within the fusion mass, which might cause the nonunion. Thereby, in order to decrease the rate of pseudarthrosis, we created a novel posterior spinal fusion method. In this technique, we utilized the advantages of the SAP and PI that they have sufficient blood supply, and there was also abundant paraspinal musculature adhered to them, successfully built the bone graft bed that four walls next to fresh bone. We have constructed the novel posterior lumbar spine fusion with orthotopic paraspinal muscle-pediculated bone flaps in canine model. And the results showed that this novel method obviously surpassed the traditional posterolateral fusion in the rapidity and quality of bone formation. 14 So the animal experiment laid substantial foundation for its clinical application. Blumenthal et al. 17 reported that the overall agreement between radiographic assessment of fusion and actual surgical results was 69%. It have been reported that it is difficulty to determine fusion status by radiography. 17 Axelsson 18 et al reported that there were some limitations in assessing fusion status with conventional radiography and flexion/extension functional radiography at early postoperative times. Hereby, three-dimensional reconstruction of CT was adopted to evaluate the fusion rate in this study. Three-dimensional reconstruction of CT estimated lumbar fusion from three different viewing angles, which was more accurate and comprehensive than radiography. In this study, the overall fusion rate determined by CT scan was more than 90%, significantly higher than the traditional posterolateral fusion described by An 19 and Wang 4 . In their study, CT was not used to evaluate the fusion rate, so our results have great advantages. Parvizi 20 considered that blood supply of bone graft was extremely important for bone union. In this study, the initial clinical result showed that solid fusion was formed at three months after surgery in several cases, which was better than six months of posterolateral lumbar fusion which reported by Howard 21 . It is obviously the novel posterior spinal fusion possessed significant dominance in the rapidity of bone formation. In the animal and clinical experiment, we discovered that the bone healing initially occurred near the muscle-bone flaps. This phenomenon coincided with Parvizi’s view point again: the blood supply of bone graft had a direct influence on bone union. In our study, the VAS back pain score of postoperative was significantly better than Owens 22 and Park's 23 report. The analysis may have preserved the spinous process ligament system and the function of muscle ligament complex with our operation, so as to reduce the occurrence of low back pain symptoms. Therefore, it shows the advantage of our operation with less injury. We conclude that the reasons of the rapid bone formation in this novel model could be speculated as follows: (1) Larger graft beds and shorter distance for fusion: In this novel posterior spinal fusion model, we split the bilateral outer margin of SAPs and superior border of transverse processes of L5 and outer margin of pars interarticulares (PIs) and inferior border of L4, and constructed a graft bed that four walls next to fresh sclerotin, which obviously increased the area of graft bed. The more fresh sclerotin of the graft bed, the more nutrient was supplied by the tissues of surrounding. (2) Bone grafts could get blood supply from paraspinal muscle: Bawa 15 reported that paraspinal muscle can provide a rich vascular supply for the fusion mass. In this study, paraspinal muscle adhered to the lateral parietes of graft bed, and provided blood supply for bone graft. So the bone grafts can get better blood supply than posterolateral intertransverse process fusion. (3) Mechanically holding the bone graft, limiting the movement of the graft: the bone grafts were placed in the proximate cuboid graft bed,and were closely presses by superior titanium rods. So the graft beds could limit the movement of the graft. Meanwhile, the lateral bone flaps prevented paraspinal muscles interposing in grafts, which removed the influence of soft tissue in bone healing. (4) Might help induce the expression of bone growth factors: Kakar 24 and Chen 25 report that some morphogenetic factors and their receptors that promoted the growth of skeletal tissues, such as BMPs and FGFs, which were expressed during fracture healing. In our study, the process of splitting bone equivalently created minor fracture which might help induce the expression of bone growth factors and accelerate bone healing. In addition, we found that local autologous corticocancellous from decompression by fenestration was enough for fusion in the novel technology, avoiding the morbidity of harvesting the iliac wing for autogenous bone. In my opinion, the novel posterior spinal fusion method had extremely wide perspective for clinical application. Conclusions The novel posterior lumbar fusion method decreased the incidence rate of pseudarthrosis, and could get well-content clinical effect. Nevertheless, further researches are needed to determine the long-term clinical result of this novel technology. Therefore, we believe that this technique can be widely used in lumbar degenerative instability disease substitute for posterolateral transverse process fusion and most interbody fusion. Declarations Declarations Ethics approval and consent to participate: In accordance with local and institutional laws and data protection regulations, no approval by the local ethics committee was necessary for this study. Consent for publication: Not applicable Availability of data and materials: All data generated or analysed during this study are included in this published article. Competing interests: The authors declare that they have no competing interests. Funding: No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Authors' contributions: ChunyangXi and HuiChi analyzed and interpreted the patient data. JinglongYan performed the operation. WenxiaoXu, GuangxiWang, PengyuKong and YufuWang draft the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors thank Zhipeng Zhang, Jingjun Xia, Lei Zhou, Ye Ji for their technical expertise. References Polly DW Jr, Santos ER, Mehbod AA. Surgical treatment for the painful motion segment: matching technology with the indications: posterior lumbar fusion. Spine. 2005;30(16 Suppl):44–51. Tajima N, Chosa E, Watanabe S. Posterolateral lumbar fusion. J Orthop Sci. 2004;9(3):327–33. Wang JC, Mummaneni PV, Haid RW. Current treatment strategies for the painful lumbar motion segment: posterolateral fusion versus interbody fusion. Spine 2005;30(16 Suppl):S33-S43. Wang C, Yin X, Zhang L, et al. Posterolateral fusion combined with posterior decompression shows superiority in the treatment of severe lumbar spinal stenosis without lumbar disc protrusion or prolapse: a retrospective cohort study. J Orthop Surg Res. 2020;15(1):26. Farrokhi MR, Yadollahikhales G, Gholami M, et al. Clinical Outcomes of Posterolateral Fusion vs. Posterior Lumbar Interbody Fusion in Patients with Lumbar Spinal Stenosis and Degenerative Instability. Pain Physician. 2018;21(4):383–406. Cho JH1, Lee JH2, Yeom JS3, et al. Efficacy of Escherichia coli-derived recombinant human bone morphogenetic protein-2 in posterolateral lumbar fusion: an open, active-controlled, randomized, multicenter trial.Spine J. 2017 Dec;17(12):1866-74. Zheng GB, Yoon BH, Lee JH. Comparison of the osteogenesis and fusion rates between activin A/BMP-2 chimera (AB204) and rhBMP-2 in a beagle's posterolateral lumbar spine model.Spine J. 2017 Oct;17(10):1529–36. Coughlan M, Davies M, Mostert AK, et al. A Prospective, Randomized, Multicenter Study Comparing Silicated Calcium Phosphate versus BMP-2 Synthetic Bone Graft in Posterolateral Instrumented Lumbar Fusion for Degenerative Spinal Disorders.Spine (Phila Pa 1976). 2018 Aug 1;43(15):E860-E868. Carragee EJ, Hurwitz EL, Weiner BK. A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned. Spine J. 2011;11:471–91. Lewandrowski KU, Nanson C, Calderon R. Vertebral osteolysis after posterior interbody lumbar fusion with recombinant human bone morphogenetic protein 2: a report of five cases. Spine J. 2007;7:609–14. Smucker JD, Petersen EB, Fredericks DC. Assessment of MASTERGRAFT PUTTY as a graft extender in a rabbit posterolateral fusion model.Spine (Phila Pa 1976). 2012 May 20;37(12):1017–21. Walsh WR, Vizesi F, Cornwall GB, et al. Posterolateral spinal fusion in a rabbit model using a collagen-mineral composite bone graft substitute. Eur Spine J. 2009;18(11):1610–20. Bawa M, Schimizzi AL, Leek B, et al. Paraspinal muscle vasculature contributes to posterolateral spinal fusion. Spine. 2006;31:891–6. Chunyang Xi Y, Li Z, Chi, et al. The Influence of Orthotopic Paraspinal Muscle-Pediculated Bone Flaps on Posterior Spinal Fusion in a Canine Model. Spine. 2011;36:E20–6. Glassman SD, Dimar JR, Carreon LY, et al. Initial fusion rates with recombinant human bone morphogenetic protein-2/compression resistant matrix and a hydroxyapatite and tricalcium phosphate/collagen carrier in posterolateral spinal fusion. Spine (Phila Pa 1976). 2005;30(15):1694–8. Glazer PA, Heilmann MR, Lotz JC, et al. Use of ultrasound in spinal arthrodesis: A rabbit model. Spine. 1998;23:1142–8. Blumenthal SL, Gill K. Can lumbar spine radiographs accurately determine fusion in post-operative patients? Correlation of routine radiographs with a second look at lumbar fusions. Spine. 1993;18:1186–9. Axelsson P, Johnsson R, Strömqvist B, et al. Posterolateral lumbar fusion. Outcomes of 71 consecutive operations after 4 (2–7) years. Acta Orthop Scand. 1994;65:309–14. An KC, Kong GM, Park DH, et al. Comparison of posterior lumbar interbody fusion and posterolateral lumbar fusion in monosegmental vacuum phenomenon within an intervertebral disc. Asian Spine J. 2016;10(1):93–8. Parvizi J, Wu CC, Lewallen DG, et al. Low-intensity ultrasound stimulates proteoglycan synthesis in rat chondrocytes by increasing aggrecan gene expression. J Orthop Res. 1999;17:488–94. Howard JM, Glassman SD, Carreon LY, et al. Posterior iliac crest pain after posterolateral fusion with or without iliac crest graft harvest. Spine J. 2011;11:534–7. Owens RK, Djurasovic, Onyekwelu, et al. Outcomes and revision rates in normal, overweight, and obese patients 5 years after lumbar fusion. Spine J. 2016;16(10):1178–83. Park JS, Lee CS, Park SJ, et al. Minimum three-year follow-up of Specific functional disabilities after multilevel lumbar fusion:comparison of long-level and short-level fusion. Spine (Phila Pa 1976). 2019;44(20):1418–25. Kakar S, Einhorn TA, Vora S, et al. Enhanced chondrogenesis and wnt signaling in parathyroid hormone treated fractures. J Bone Miner Res. 2007;22:1903–12. Chen Y, Alman BA. Wnt pathway, an essential role in bone regeneration. J Cell Biochem. 2009;106:353–62. Tables Table 1. Grades of fusion as observed by computed tomography Table 2. VAS, ODI and SF-36 of preoperation and at the different follow-up intervals Time VAS (leg pain) VAS (back pain) ODI SF-36(PCS) SF-36(MCS) preoperation 7.08±1.77 6.25±2.17 49.72±14.17 28.48±16.18 39.64±14.84 6 months 2.36±0.97 * 1.97±0.79 * 17.21±6.91 * 68.55±11.06 * 73.62±13.32 * 1 year 2.55±0.95 * 2.22±0.82 * 18.26±4.25 * 67.83±10.57 * 70.68±11.91 * last follow-up 2.69±1.05 * 2.39±0.95 * 18.75±4.64 * 65.91±9.97 * 73.76±8.06 * Note：*=P<0.01, (postoperation vs preoperation ) Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 25 Apr, 2021 Reviewer # 3 agreed at journal 04 Apr, 2021 Review # 2 received at journal 04 Apr, 2021 Review # 1 received at journal 01 Apr, 2021 Reviewer # 2 agreed at journal 31 Mar, 2021 Reviewer # 1 agreed at journal 29 Mar, 2021 Reviewers invited by journal 21 Feb, 2021 Editor assigned by journal 23 Jan, 2021 Submission checks completed at journal 23 Jan, 2021 Editor invited by journal 23 Jan, 2021 First submitted to journal 21 Jan, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-286003","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":14128518,"identity":"5c1fe086-061f-4b9b-8802-00002fcc1dc5","order_by":0,"name":"Chun yang Xi","email":"","orcid":"","institution":"Harbin Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chun","middleName":"yang","lastName":"Xi","suffix":""},{"id":14128519,"identity":"06327f98-4c18-4021-b7ed-28bf847d725f","order_by":1,"name":"chi hui","email":"","orcid":"https://orcid.org/0000-0003-1958-474X","institution":"Harbin Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"chi","middleName":"","lastName":"hui","suffix":""},{"id":14128520,"identity":"aad135b4-3392-4314-996e-79696f210a0e","order_by":2,"name":"Wenxiao XU","email":"","orcid":"","institution":"Harbin medical university","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wenxiao","middleName":"","lastName":"XU","suffix":""},{"id":14128521,"identity":"f92ce228-00e3-442d-b171-54c5ffcc805f","order_by":3,"name":"Guang xi Wang","email":"","orcid":"","institution":"Harbin Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Guang","middleName":"xi","lastName":"Wang","suffix":""},{"id":14128522,"identity":"cc7145b8-8170-4d34-a07d-be51c495138e","order_by":4,"name":"Peng yu Kong","email":"","orcid":"","institution":"Harbin Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Peng","middleName":"yu","lastName":"Kong","suffix":""},{"id":14128523,"identity":"836af64d-df83-47ee-966a-d35db8e9788b","order_by":5,"name":"Yu fu Wang","email":"","orcid":"","institution":"Harbin medical university","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yu","middleName":"fu","lastName":"Wang","suffix":""},{"id":14128524,"identity":"66fd6773-ea94-4eb4-8a16-d80ba6683c20","order_by":6,"name":"Jing long Yan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYJACgwQGBhkw60OFhBw/sVp4QAzGGWcsjCUbiLQJrIWZs60icQMhLQbHzx4oeLijlodfuv3ya8Z5EowbGJgfPrqBT8uZvASDxDPHeSTnnCmzLtwmwWzOwGZsnINPy4EcA4PEtmM8Bjdy0oxnbpNgs2zgYZPGq+X8GyQtvHMkeAwOENJyA2xLDVBL+uHHvA0SEgS1SN4A23KAR3JGDhvjjGMSBpLNBPzCdz7HzPBnW50cv0T64w8faurq+9mbHz7Gp0XhAAObAQPDYSCTx0wCLMSMRzkIyDcwMD9gYKgDMtkffyCgeBSMglEwCkYoAAD1Pk9wuww6RgAAAABJRU5ErkJggg==","orcid":"","institution":"Harbin medical university","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jing","middleName":"long","lastName":"Yan","suffix":""}],"badges":[],"createdAt":"2021-02-28 15:22:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-286003/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-286003/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":6542119,"identity":"a88d5d5b-9a59-4302-8cb9-109a74af756a","added_by":"auto","created_at":"2021-03-02 21:43:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":371745,"visible":true,"origin":"","legend":"Schematic diagram of the novel posterior lumbar fusion demonstrates the position of split bone and the site of bone graft. ","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-286003/v1/b5889c8de653ddb18ff71376.png"},{"id":6542120,"identity":"ac5c6a72-4a5e-4eac-90d7-7335b841b52e","added_by":"auto","created_at":"2021-03-02 21:43:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1769413,"visible":true,"origin":"","legend":"The MRI of lumbar showed spinal stenosis and intervertebral instability of L4-5 level (a, b).","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-286003/v1/93b42173727877186769943c.png"},{"id":6542121,"identity":"20b58f82-bdcc-4797-8e02-d6c97997a13b","added_by":"auto","created_at":"2021-03-02 21:43:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1169351,"visible":true,"origin":"","legend":"(a, b): Postoperative anteroposterior and lateral radiograph demonstrated the state of internal fixation. The arrow showed a continuous bone bridge formed between the transverse processes.","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-286003/v1/ad6f03c72952a2f36383c539.png"},{"id":6541933,"identity":"17a6e24a-911f-4b52-84cb-242fc57f4cc5","added_by":"auto","created_at":"2021-03-02 21:40:37","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1971374,"visible":true,"origin":"","legend":"Three dimensional computed tomography scan at 6 months after surgery displayed that continuous bone bridge have formed between SPAs (a, b). (b): Sagittal reconstruction of a CT scan demonstrated that the continuous bony mass was present bilaterally with no evidence of lucent lines. (c): Horizontal reconstruction of a CT scan showed that fusion masses were under the internal fixator rods. (d): Coronal reconstruction of a CT scan demonstrated that the articular facets of L4-5 level have disappeared and were substituted by continuous bone bridge.","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-286003/v1/b1ac3d91f41225edf6531ec9.png"},{"id":6541932,"identity":"0d9dfe0e-cf91-4a90-b1f4-c9a2e2bda1eb","added_by":"auto","created_at":"2021-03-02 21:40:37","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2402950,"visible":true,"origin":"","legend":"Three dimensional computed tomography scan at 1 year after surgery displayed that continuous bone bridge have formed between SPAs (a, b, d). And the bone bridge was more mature than 6 months (b, c, d).\n\n","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-286003/v1/1f6f6977d4fd191bbcb11d3e.png"},{"id":13673763,"identity":"545eb201-927c-45d0-bc1e-af4186fdfac5","added_by":"auto","created_at":"2021-09-17 11:18:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6649197,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-286003/v1/ee7de461-285c-470f-8b07-dad529f9e7ea.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eA Novel Posterior Spinal Fusion Technology with Local Bone for a Degenerative Spine: A Preliminary Report of 48 Cases\u003c/p\u003e","fulltext":[{"header":"Introduction","content":" \u003cp\u003eIt is considered that lumbar spine fusion is a primary procedure for patients with degenerative spinal disorders to maintain spinal stability and prevent postoperative instability.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Though some kinds of lumbar fusion techniques have exist, posterolateral lumbar fusion (PLF) is always considered to be the gold standard for lumbar spinal fusion.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Although anterior interbody fusion techniques have been developed and continue to be evolved, the traditional technique of posterolateral fusion is still the most commonly performed type of fusion in the lumbar spine.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e The lower complication rate, lesser surgical blood loss, shorter operative time, and lesser cost associated with this technique as compared with an interbody procedure make this an attractive option to treat spinal disease.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Unfortunately, solid fusion is not always acquired. Documented nonunion rates range from 10\u0026ndash;40% for posterolateral lumbar fusion,\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e despite the extensive use of internal fixation in the clinical setting. Failure of fusion usually brings a number of troubles to patients and surgeons. Thereby, it is necessary to adopt several measures to reduce or eliminate the incidence of nonunion.\u003c/p\u003e \u003cp\u003eRecently, many researches are focused on biological substances of fusion by the addition of BMPs, demineralized bone matrix, and osteoprogenitor cells to the bone graft.\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e However, many researchers have been concerns about the complications such as airway edema, seroma formation, soft tissue swelling, retrograde ejaculation, carcinogenicity, bone osteolysis and ectopic bone formation.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e So these complications affect their extensive application.\u003c/p\u003e \u003cp\u003eMany areas can provide a blood supply for bone graft area, such as local bone and muscle tissue. Smucker\u003csup\u003e11\u003c/sup\u003eand Walsh\u003csup\u003e12\u003c/sup\u003eet al studied posterolateral transverse processes fusion in a rabbit model. They revealed that the fusion firstly took place at decorticated transverse processes. This suggested that local decorticated bone may offer a key vascular supply for fusion masses. However, Bawa\u003csup\u003e13\u003c/sup\u003eet al investigated the contribution of paraspinal musculature to posterolateral fusion masses in a rabbit model. They considered that the paraspinal musculature provided crucial vascular ingrowth into the fusion site. The blood supply from local decorticated bone and muscle tissue were equally important for spine fusion, but little attention was paid to the role of muscle tissue. Presently, there were no a posterior arthrodesis that could simultaneouly use the blood supply from local decorticated bone and muscle tissue.\u003c/p\u003e \u003cp\u003eFor this reason, authors of this study designed a novel posterior lumbar spine arthrodesis with paraspinal Muscle-pediculated bone grafts, and hoped to provide a spinal fusion method with generally application, high union rate and minor paraspinal soft tissue injury. We have proved the advantage in bone formation rate and quality of the novel method by animal experiment.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e And we have applied the novel bone graft method to clinical patients. So we evaluated the initial clinical result.\u003c/p\u003e "},{"header":"Materials And Methods","content":"\u003cp\u003eA total of 48 consecutive cases, operated during 2011 and 2014 by the senior author for degenerative spinal disorders, were reviewed. One spinal surgical team treated all enrolled patients, and all patients were operated by the same surgeon. Before surgery, patients underwent dual-energy x-ray absorptiometry to assess bone mineral density. All participants met the following inclusion criteria: (1) failure of conservative treatment after a minimum of 6 months; (2) age, 65 years or less; (3) undergoing lumbar fusion surgery at a single level(L4-5); and (4) a follow-up period of 2 years or more after surgery. Exclusion criteria were as follows: (1) Severe osteoporosis; (2) Patients who have had lumbar surgery; (3) abnormal muscle activity or ambulation due to neuromuscular disease; and (4) unable to accurately complete the pre- and postoperative questionnaires due to certain problems such as a stroke or dementia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing standard aseptic techniques, a midline skin incision was made from levels of L4\u0026ndash;L5. Paraspinal muscles were stripped subperiosteally from the spinous processes and laminae until superior articular processes (SAPs) were seen. After C-arm examining for determining the segment, pedicle screws were inserted to L4 and L5, bilateral decompression by fenestration at the level of L4-5. The bilateral outer margin of SAPs of L5 and outer margin of pars interarticulares (PIs) and inferior border accessory process of L4 were lengthways split by sharp osteotome. Blunt dissection was used to separate the split bone flaps and the adherent longissimus and multifidus muscles to form cuboid bed of bone graft that four walls next to fresh sclerotin. Autologous corticocancellous from decompression by fenestration was cleaned, trimmed, and morselized with a rongeur and placed over the graft bed. Suitable length titanium rods were placed over the graft bed and were used to connect pedicle screws. Screwed up the screw cap, and placed drainage tube. The wound was closed in a standard manner. (Figure 1 )\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRadiographic Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRadiologic outcome was assessed independently by three orthopedic surgeons, and the radiographic fusion rate was calculated at each time-period by averaging the results of the three observers. Plain anteroposterior were presented before and 3, 6, 12 months after surgery, and at the last follow-up, and were used to evaluate the position of internal fixation. Because of the occlusion of internal fixation, the fusion status was assessed by three-dimensional reconstruction of CT at at 6 months and 1 year after surgery. Sequential bony bridges formed in coronal Plane and sagittal plane between intertransverses or SAPs was considered as solid fusion. CT scans were graded according to the method of Glassman.\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e5\u003c/sup\u003e CT scans were graded as demonstrating no fusion (grade 1), partial or limited unilateral fusion (grade 2), partial or limited bilateral fusion (grade 3), solid unilateral fusion (grade 4), or solid bilateral fusion (grade 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative follow-up was performed at 3 months, 6 months, 12 months and the last follow-up. Preoperative baseline and postoperative outcome measures at 6months, 12 months and the last follow-up included Visual Analogue Scale (VAS,range 0\u0026ndash;10) for back and leg pain, the Oswestry Disability Index (ODI) and the Short Form-36 (SF-36). The mean score (range: 0, normal to 5, impossible) for each of the 10 ODI items was determined separately. Analysis of the item related to sex life was not included owing to the small number of respondents. Thus, scores ranged from 0 to 45.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed using the SPSS 22.0 software package. The VAS ODI, and SF-36 scores were analyzed by Kruskal-Wallis one-way analysis of variance (ANOVA). The fusion results were compared statistically using McNemar\u0026rsquo;s \u0026chi; \u003csup\u003e2\u003c/sup\u003etest. Significance was defined by P values \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":" \u003cp\u003e\u003cstrong\u003ePatient Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient cohort included 22 men and 26 women, with an average age of 60.3\u0026plusmn;11.7 years (range, 37\u0026ndash;65 years). All the cases had decompression by fenestration and novel posterior lumbar fusion with pedicle screw instrumentation. The diagnosis included degenerative spinal stenosis in 15 (31.3%), degenerative spondylolisthesis with stenosis in 28 (58.3%), spondylolisthesis with disc degeneration in 5 (10.4%). Fusion was performed at level of L4-5. Minimum follow-up was 28 months (mean, 39.4 months; range, 28-51 months). Typical case images are shown in Figure 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperation data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients successfully completed the operation without iatrogenic nerve injury. The surgical time was 1.85\u0026plusmn;0.4 hours and the estimated blood loss was 158.6\u0026plusmn;18.3mL. The drainage tubes were pulled out 48-72 hours after operation, and the patients got out of bed with brace 3 days after surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRadiological evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe plain anteroposterior showed that loosening and breakage of internal fixation were not take place at the last follow-up. (Figure 3) At 6 months after surgery, the results from the three-dimensional reconstruction of CT displayed that solid fusion was observed in 44 of 48 (91.7%) segments, and the unilateral fusion was showed in 3 of 44 (6.8%) segments. At 1 year after surgery, the results from the three-dimensional reconstruction of CT displayed that solid fusion was observed in 46 of 48 (95.8%) segments, and the unilateral fusion was showed in 2 of 46 (4.3%) segments. There was no significant difference in fusion rate between 6 months and 1 year after operation(P\u0026gt;0.05). Mean fusion grade (scale 1\u0026ndash;5) was 4.71 at 6 months after surgery and 4.77 at 1-year after surgery (Table 1). Typical CT images after operation are shown in Figure 4 and Figure 5.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Score\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt every postoperative interval, statistically significant improvement from baseline was observed for VAS back and leg pain scores(P\u0026lt;0.01). However, VAS back pain score seems to maintain a better score. (Table 2) Statistically significant improvement was also seen for ODI, SF-36(PCS) and SF-36(MCS)(P\u0026lt;0.01). All the postoperative scores except SF-36 (MCS) were the best at 6 months postoperatively compard with the other time nodes. And there was little change in SF-36 (MCS) score at three time points after operation.\u003c/p\u003e"},{"header":"Discussion","content":" \u003cp\u003eFailure or delay in spinal arthrodesis can result in contumacious low back pain, which bring about tremendous pain to patients, and usually need the second operation. Successful spinal fusion requires a suitable local environment that has sufficient surface area of decorticated host bone, adequate graft material, absence of excessive motion, and a rich vascular supply.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e In a rabbit\u0026rsquo;s posterolateral intertransverse process fusion model, Smucker\u003csup\u003e11\u003c/sup\u003eet al found neovascularization derived mainly from the decorticated transverse processes, and healing initially occurred near the transverse processes and delayed in the central site. So they considered that the main reason of nonunion might be the fusion mass delay in vascularization of the central region. Bawa\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e presumed that the muscle helped fasten attach the graft to the local bone, but sometimes its interposition may lead to a fibrous cleft within the fusion mass, which might cause the nonunion.\u003c/p\u003e \u003cp\u003eThereby, in order to decrease the rate of pseudarthrosis, we created a novel posterior spinal fusion method. In this technique, we utilized the advantages of the SAP and PI that they have sufficient blood supply, and there was also abundant paraspinal musculature adhered to them, successfully built the bone graft bed that four walls next to fresh bone. We have constructed the novel posterior lumbar spine fusion with orthotopic paraspinal muscle-pediculated bone flaps in canine model. And the results showed that this novel method obviously surpassed the traditional posterolateral fusion in the rapidity and quality of bone formation.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e So the animal experiment laid substantial foundation for its clinical application.\u003c/p\u003e \u003cp\u003eBlumenthal et al.\u003csup\u003e17\u003c/sup\u003ereported that the overall agreement between radiographic assessment of fusion and actual surgical results was 69%. It have been reported that it is difficulty to determine fusion status by radiography.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Axelsson\u003csup\u003e18\u003c/sup\u003eet al reported that there were some limitations in assessing fusion status with conventional radiography and flexion/extension functional radiography at early postoperative times. Hereby, three-dimensional reconstruction of CT was adopted to evaluate the fusion rate in this study. Three-dimensional reconstruction of CT estimated lumbar fusion from three different viewing angles, which was more accurate and comprehensive than radiography. In this study, the overall fusion rate determined by CT scan was more than 90%, significantly higher than the traditional posterolateral fusion described by An\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e and Wang\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. In their study, CT was not used to evaluate the fusion rate, so our results have great advantages.\u003c/p\u003e \u003cp\u003eParvizi\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e considered that blood supply of bone graft was extremely important for bone union. In this study, the initial clinical result showed that solid fusion was formed at three months after surgery in several cases, which was better than six months of posterolateral lumbar fusion which reported by Howard\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. It is obviously the novel posterior spinal fusion possessed significant dominance in the rapidity of bone formation. In the animal and clinical experiment, we discovered that the bone healing initially occurred near the muscle-bone flaps. This phenomenon coincided with Parvizi\u0026rsquo;s view point again: the blood supply of bone graft had a direct influence on bone union.\u003c/p\u003e \u003cp\u003eIn our study, the VAS back pain score of postoperative was significantly better than Owens\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e and Park's\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e report. The analysis may have preserved the spinous process ligament system and the function of muscle ligament complex with our operation, so as to reduce the occurrence of low back pain symptoms. Therefore, it shows the advantage of our operation with less injury.\u003c/p\u003e \u003cp\u003eWe conclude that the reasons of the rapid bone formation in this novel model could be speculated as follows: (1) Larger graft beds and shorter distance for fusion: In this novel posterior spinal fusion model, we split the bilateral outer margin of SAPs and superior border of transverse processes of L5 and outer margin of pars interarticulares (PIs) and inferior border of L4, and constructed a graft bed that four walls next to fresh sclerotin, which obviously increased the area of graft bed. The more fresh sclerotin of the graft bed, the more nutrient was supplied by the tissues of surrounding. (2) Bone grafts could get blood supply from paraspinal muscle: Bawa\u003csup\u003e15\u003c/sup\u003ereported that paraspinal muscle can provide a rich vascular supply for the fusion mass. In this study, paraspinal muscle adhered to the lateral parietes of graft bed, and provided blood supply for bone graft. So the bone grafts can get better blood supply than posterolateral intertransverse process fusion. (3) Mechanically holding the bone graft, limiting the movement of the graft: the bone grafts were placed in the proximate cuboid graft bed,and were closely presses by superior titanium rods. So the graft beds could limit the movement of the graft. Meanwhile, the lateral bone flaps prevented paraspinal muscles interposing in grafts, which removed the influence of soft tissue in bone healing. (4) Might help induce the expression of bone growth factors: Kakar\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e and Chen\u003csup\u003e25\u003c/sup\u003ereport that some morphogenetic factors and their receptors that promoted the growth of skeletal tissues, such as BMPs and FGFs, which were expressed during fracture healing. In our study, the process of splitting bone equivalently created minor fracture which might help induce the expression of bone growth factors and accelerate bone healing. In addition, we found that local autologous corticocancellous from decompression by fenestration was enough for fusion in the novel technology, avoiding the morbidity of harvesting the iliac wing for autogenous bone. In my opinion, the novel posterior spinal fusion method had extremely wide perspective for clinical application.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eThe novel posterior lumbar fusion method decreased the incidence rate of pseudarthrosis, and could get well-content clinical effect. Nevertheless, further researches are needed to determine the long-term clinical result of this novel technology. Therefore, we believe that this technique can be widely used in lumbar degenerative instability disease substitute for posterolateral transverse process fusion and most interbody fusion.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDeclarations\u003c/b\u003e \u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn accordance with local and institutional laws and data protection regulations, no approval by the local ethics committee was necessary for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChunyangXi and HuiChi analyzed and interpreted the patient data. JinglongYan performed the operation. WenxiaoXu, GuangxiWang, PengyuKong and YufuWang draft the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Zhipeng Zhang, Jingjun Xia, Lei Zhou, Ye Ji for their technical expertise.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePolly DW Jr, Santos ER, Mehbod AA. Surgical treatment for the painful motion segment: matching technology with the indications: posterior lumbar fusion. Spine. 2005;30(16 Suppl):44\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTajima N, Chosa E, Watanabe S. Posterolateral lumbar fusion. J Orthop Sci. 2004;9(3):327\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang JC, Mummaneni PV, Haid RW. Current treatment strategies for the painful lumbar motion segment: posterolateral fusion versus interbody fusion. Spine 2005;30(16 Suppl):S33-S43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang C, Yin X, Zhang L, et al. Posterolateral fusion combined with posterior decompression shows superiority in the treatment of severe lumbar spinal stenosis without lumbar disc protrusion or prolapse: a retrospective cohort study. J Orthop Surg Res. 2020;15(1):26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFarrokhi MR, Yadollahikhales G, Gholami M, et al. Clinical Outcomes of Posterolateral Fusion vs. Posterior Lumbar Interbody Fusion in Patients with Lumbar Spinal Stenosis and Degenerative Instability. Pain Physician. 2018;21(4):383\u0026ndash;406.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCho JH1, Lee JH2, Yeom JS3, et al. Efficacy of Escherichia coli-derived recombinant human bone morphogenetic protein-2 in posterolateral lumbar fusion: an open, active-controlled, randomized, multicenter trial.Spine J. 2017 Dec;17(12):1866-74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZheng GB, Yoon BH, Lee JH. Comparison of the osteogenesis and fusion rates between activin A/BMP-2 chimera (AB204) and rhBMP-2 in a beagle's posterolateral lumbar spine model.Spine J. 2017 Oct;17(10):1529\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCoughlan M, Davies M, Mostert AK, et al. A Prospective, Randomized, Multicenter Study Comparing Silicated Calcium Phosphate versus BMP-2 Synthetic Bone Graft in Posterolateral Instrumented Lumbar Fusion for Degenerative Spinal Disorders.Spine (Phila Pa 1976). 2018 Aug 1;43(15):E860-E868.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarragee EJ, Hurwitz EL, Weiner BK. 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Eur Spine J. 2009;18(11):1610\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBawa M, Schimizzi AL, Leek B, et al. Paraspinal muscle vasculature contributes to posterolateral spinal fusion. Spine. 2006;31:891\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChunyang Xi Y, Li Z, Chi, et al. The Influence of Orthotopic Paraspinal Muscle-Pediculated Bone Flaps on Posterior Spinal Fusion in a Canine Model. Spine. 2011;36:E20\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGlassman SD, Dimar JR, Carreon LY, et al. Initial fusion rates with recombinant human bone morphogenetic protein-2/compression resistant matrix and a hydroxyapatite and tricalcium phosphate/collagen carrier in posterolateral spinal fusion. Spine (Phila Pa 1976). 2005;30(15):1694\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGlazer PA, Heilmann MR, Lotz JC, et al. 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J Cell Biochem. 2009;106:353\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. \u003c/strong\u003e\u003cstrong\u003eGrades of fusion as observed by computed tomography\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\" alt=\"\" /\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable\u0026nbsp;2.\u003c/strong\u003e \u003cstrong\u003eVAS, ODI and SF-36 of preoperation and at the different follow-up intervals\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"105\"\u003e\n\u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(leg pain)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(back pain)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e\u003cstrong\u003eODI\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003eSF-36(PCS)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e\u003cstrong\u003eSF-36(MCS)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"105\"\u003e\n\u003cp\u003epreoperation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e7.08\u0026plusmn;1.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e6.25\u0026plusmn;2.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e49.72\u0026plusmn;14.17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e28.48\u0026plusmn;16.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e39.64\u0026plusmn;14.84\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"105\"\u003e\n\u003cp\u003e6 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e2.36\u0026plusmn;0.97\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e1.97\u0026plusmn;0.79\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e17.21\u0026plusmn;6.91\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e68.55\u0026plusmn;11.06\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e73.62\u0026plusmn;13.32\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"105\"\u003e\n\u003cp\u003e1 year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e2.55\u0026plusmn;0.95\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e2.22\u0026plusmn;0.82\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e18.26\u0026plusmn;4.25\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e67.83\u0026plusmn;10.57\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e70.68\u0026plusmn;11.91\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"105\"\u003e\n\u003cp\u003elast follow-up\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e2.69\u0026plusmn;1.05\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e2.39\u0026plusmn;0.95\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e18.75\u0026plusmn;4.64\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e65.91\u0026plusmn;9.97\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"102\"\u003e\n\u003cp\u003e73.76\u0026plusmn;8.06\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"598\"\u003e\n\u003cp\u003eNote：*=P\u0026lt;0.01, (postoperation vs preoperation )\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lumbar fusion, Muscle-pediculated bone flaps, Local bone, Paraspinal muscle, Degenerative diseases","lastPublishedDoi":"10.21203/rs.3.rs-286003/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-286003/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThere were lower rate of solid bony union in the traditional posterolateral lumbar fusion. And previous studies have showed that paraspinal musculature provided predominant vascular ingrowth into the fusion mass. The purpose of this study was to introduce a novel posterior fusion technique which utilized orthotopic paraspinal muscle-pediculated bone flaps for increasing blood supply and accelerating the healing of local bone grafts. In addition, the feasibility, safety, and early outcome of this method were evaluated.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e 48 patients of degenerative lumbar disorders were treated with the novel posterior lumbar fusion method. To analyze early complications, rate of fusion and clinical outcome. The fusion status was assessed by three-dimensional reconstruction of CT at at 6 months and 1 year after surgery. The VAS, ODI and SF-36 were assessed pre- and postoperatively.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e All the patients were followed up for 2 years at least. No operative or postoperative complications were encountered. There was significant statistical difference in VAS, ODI and SF-36 before and after operation (P\u0026lt;0.01). Satisfactory fusion was observed at 6-months follow-up. There was only one case not formed solid fusion at the last follow-up.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The\u003cstrong\u003e \u003c/strong\u003eposterior lumbar fusion method was such a novel and useful technique that made the position of bone graft more precise and stable that it can increase the fusion rate. This method has decreased the incidence rate of pseudarthrosis, and could get satisfactory clinical outcomes.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"A Novel Posterior Spinal Fusion Technology with Local Bone for a Degenerative Spine: A Preliminary Report of 48 Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-03-02 21:40:35","doi":"10.21203/rs.3.rs-286003/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-04-26T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-04-05T00:00:00+00:00","index":3,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-04-05T00:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nThe work is devoted to the most frequent operation in spinal clinics — lumbar fusion. With the current wide spread of techniques of interbody fusion, the proposed improved method of posterior fusion looks very fresh and stands out favorably from the wide mass of studies presented in recent years.\n\nThe theoretical advantages of the described technique are presented in detail by the authors, and the clinical effectiveness is confirmed by the results of the presented study.\n\nThere are certain aspects in the work that, in my opinion, require clarification. In particular, the term \"Decompression by fenestration\" is not generally accepted and requires clarification in the text of the work. Since in my understanding — fenestartion - is the imposition of a minimum target hole in the area of the compression, with this approach, the bone-plasitic material will be clearly insufficient for conducting spondylodesis using an autotransplant.\nThe second position, which in my opinion requires clarification, is the criteria for including and excluding patients to perform this operation, for example, what are the tactics for complete disc collapse or spondylolisthesis, whether they are contraindications to this intervention.\n\n\n\nThe work should definitely be published, because It is of interest to a wide audience of spinal surgeons, after making corrections that do not affect the overall content of the work* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2021-04-02T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reject\nForm responses:\n---\n\nComments to Author:\n---\nThe patient in figure 2 had only spinal stenosis. Facet were hypertrophied without any fluid filling in the facet joints. There were no spondylolisthesis. There were no images supporting the authors claim of instability in this patient. Since this is a primary procedure, fusion surgery should not be the first indicated surgery for this patient and posterior decompression surgery only may suffice. In addition, the author did not mention in their inclusion criteria why fusion was necessary for the cohort of their patients. Proper justification on why fusion especially with instrumentations were required for patients must be clearly stated.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2021-04-01T00:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-03-30T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-02-22T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-01-24T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-01-23T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-01-23T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2021-01-22T00:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"21b043c3-3750-44ea-b570-2a41b49071dd","owner":[],"postedDate":"March 2nd, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":2717230,"name":"Orthopedics"}],"tags":[],"updatedAt":"2021-03-02T21:40:35+00:00","versionOfRecord":[],"versionCreatedAt":"2021-03-02 21:40:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-286003","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-286003","identity":"rs-286003","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}