Research 2021: Twenty years of research about the Practice of Spinal Surgery
Studying the problems that patients present with and the clinical outcomes after treatment have always been a major interest. I wrote about clinical conditions and their treatment, as well as biomechanical studies to see how our implants and instrumentation work. My education about clinical and biomechanical research began at the Mayo Clinic where I did my residency. My first clinical papers were inspired by the patients of the orthopedic staff of the Mayo Clinic in Rochester and of the Gillette Childrens’ hospital at St Paul Ramsey Hospital. My first biomechanics training occurred in the second year of Mayo Clinic residency with Dr. Edmund Y.S. Chao. My first papers about spinal surgery were inspired by work with Stephen Esses MD and William Watters MD and Weiqiang Liu PhD. Later working with John Brantigan MD and Arvo Neidry MD, I wrote about posterior lumbar interbody fusion (PLIF) with Brantigan cages and VSP plates and monoaxial screws in a series of papers. I wrote a book chapter with John Brantigan MD about Complications and pitfalls in PLIF surgery.
I first began minimally invasive lumbar fusion in 2008 with the eXtreme Lateral Interbody Fusion (XLIF) and percutaneously placed pedicle screws. These were new techniques wherein the interbody cage was uniquely positioned on the apophyseal rim of the vertebral body and were 4 times the footprint of previous cages and I immediately began biomechanical studies to determine how much supplemental fixation was necessary to obtain a fusion. Most of my XLIF biomechanics studies was written with Alex Turner PhD at NuVasive. W worked together in the first comprehensive analysis of biomechanical review of lateral lumbar fusion constructs and supplemental fixation. Later I wrote the first article about the use of these implants and instrumentation in a spondylolisthesis instability model. I wrote a book chapter about biomechanics of the lateral cages and supplemental instrumentation with Dr. Turner.
At the same time, I wrote about cervical problems such as dysphagia with cervical plates and treatment for that dysphagia. Most of this work including finite elemental analysis was done with the Laboratory of Dr. Weiqiang Liu. Most recently I have written about use of zero profile cages and supplemental minimally invasive posterior fixation to stop dysphagia with cervical surgery in an ongoing study. I have written extensively about the use of artificial disc rather than fusion in the neck with the lab of Dr. Liu. Most of these articles required a biomechanical technique called Finite element analysis a laboratory method to mathematically model clinical situations and perform stress analysis on these models. I wrote about the neuromonitoring with the NuVasive M5 system and prevention of the adverse thigh pain numbness with Ivan Chang MD.
Most recent research has been about subsidence described as a failure of fracturing of the vertebral endplate that allows an interbody cage to subside through the endplate into the bone. This causes pseudarthrosis and loss of sagittal balance. I wrote several articles describing the effect of various features and mostly about lordosis in subsidence using finite elemental analysis with the lab of Dr. Liu. Then as porous cages were introduced with ongrowth and ingrowth of bone into the various porous surfaces of cages I wrote two articles with Dr. Liu concerning porosity on different cages. This has led to my latest project into the relationship of subsidence and the new very light-weight porous cages and their effect on subsidence. I am working with the laboratory of NuVasive (Dr. Yun Peng PhD) with a biomechanical study of a novel 3-D printed cage with a lattice work and porous endplates. These studies have shown a relationship of the lightweight titanium cages with porous surfaces and optimized body struts and a decreased rate of subsidence of this cage into the bone. We have a series of articles about the stages of this expansive project into subsidence. We also have incorporating substantiating in vivo studies with ovine models supporting our hypothesis that light weight titanium cages with porosity encourage fusion with decreasing risk of subsidence of the cage into the bone. This year I will present our subsidence data at several conferences including ORS, ISASS, NASS, and SMISS. We have completed our first subsidence and porosity manuscript for publication. Future studies in spinal surgery implants and instrumentation will continue. There are exciting changes in spinal surgery. There is much to do and learn about.
Bibliography of Doctor Guy Fogel
1. Fogel GR, Katoh Y, Rand JA, et al. Talonavicular arthrodesis for isolated arthrosis: 9.5-year results and gait analysis. Foot Ankle 1982;3:105-13.
2. Fogel GR, Sim FH. Reconstruction of ankle malunion: indications and results. Orthopedics 1982;5:1471-9.
3. Fogel GR, Younge DA, Dobyns JH. Pitfalls in the diagnosis of the simple wrist ganglion. Orthopedics 1983;6:990-2.
4. Fogel GR, McElfresh EC, Peterson HA, et al. Management of deformities of the forearm in multiple hereditary osteochondromas. J Bone Joint Surg Am 1984;66:670-80.
5. Fogel GR, Morrey BF. Delayed open reduction and fixation of ankle fractures. Clin Orthop Relat Res 1987:187-95.
6. Miller ME, Fogel GR, Dunham WK. Salmonella spondylitis. A review and report of two immunologically normal patients. J Bone Joint Surg Am 1988;70:463-6.
7. Fogel GR, Esses SI. Hip spine syndrome: management of coexisting radiculopathy and arthritis of the lower extremity. Spine J 2003;3:238-41.
8. Fogel GR, Esses SI, Calvillo O. Management of chronic limb pain with spinal cord stimulation. Pain Pract 2003;3:144-51.
9. Fogel GR, Liu W, Reitman CA, et al. Cervical plates: comparison of physical characteristics and in vitro pushout strength. Spine J 2003;3:118-24.
10. Fogel GR, Reitman CA, Liu W, et al. Physical characteristics of polyaxial-headed pedicle screws and biomechanical comparison of load with their failure. Spine (Phila Pa 1976) 2003;28:470-3.
11. Fogel GR, Cunningham PY, 3rd, Esses SI. Surgical evaluation and management of symptomatic lumbosacral meningeal cysts. Am J Orthop (Belle Mead NJ) 2004;33:278-82.
12. Fogel GR, Cunningham PY, 3rd, Esses SI. Coccygodynia: evaluation and management. J Am Acad Orthop Surg 2004;12:49-54.
13. Reitman CA, Nguyen L, Fogel GR. Biomechanical evaluation of relationship of screw pullout strength, insertional torque, and bone mineral density in the cervical spine. J Spinal Disord Tech 2004;17:306-11.
14. Fogel GR, Cunningham PY, 3rd, Esses SI. Spinal epidural lipomatosis: case reports, literature review and meta-analysis. Spine J 2005;5:202-11.
15. Fogel GR, McDonnell MF. Surgical treatment of dysphagia after anterior cervical interbody fusion. Spine J 2005;5:140-4.
16. Fogel GR, Toohey JS, Neidre A, et al. Outcomes of L1-L2 posterior lumbar interbody fusion with the Lumbar I/F cage and the variable screw placement system: reporting unexpected poor fusion results at L1-L2. Spine J 2006;6:421-7.
17. Toohey JS, Stromberg L, Neidre A, et al. Treatment of cervical pseudarthrosis after Smith-Robinson procedure with Halifax clamp fixation. J Surg Orthop Adv 2006;15:201-2.
18. Bozarth GR, Fogel GR, Toohey JS, et al. Repair of pars interarticularis defect with a modified cable-screw construct. J Surg Orthop Adv 2007;16:79-83.
19. Fogel GR, Toohey JS, Neidre A, et al. Is one cage enough in posterior lumbar interbody fusion: a comparison of unilateral single cage interbody fusion to bilateral cages. J Spinal Disord Tech 2007;20:60-5.
20. Fogel GR, Toohey JS, Neidre A, et al. Fusion assessment of posterior lumbar interbody fusion using radiolucent cages: X-ray films and helical computed tomography scans compared with surgical exploration of fusion. Spine J 2008;8:570-7.
21. Fogel GR, Toohey JS, Neidre A, et al. Outcomes of posterior lumbar interbody fusion with the 9-mm width lumbar I/F cage and the variable screw placement system. J Surg Orthop Adv 2009;18:77-82.
22. Cappuccino A, Cornwall GB, Turner AW, et al. Biomechanical analysis and review of lateral lumbar fusion constructs. Spine (Phila Pa 1976) 2010;35:S361-7.
23. Fogel GR, Li Z, Liu W, et al. In vitro evaluation of stiffness and load sharing in a two-level corpectomy: comparison of static and dynamic cervical plates. Spine J 2010;10:417-21.
24. Fogel GR, Parikh RD, Ryu SI, et al. Biomechanics of lateral lumbar interbody fusion constructs with lateral and posterior plate fixation: laboratory investigation. J Neurosurg Spine 2014;20:291-7.
25. Fogel GR, Turner AW, Dooley ZA, et al. Biomechanical stability of lateral interbody implants and supplemental fixation in a cadaveric degenerative spondylolisthesis model. Spine (Phila Pa 1976) 2014;39:E1138-46.
26. Fogel GR, Ryu SI, Parikh RD, et al. Response. J Neurosurg Spine 2015;23:260-1.
27. Li Y, Fogel GR, Liao Z, et al. Finite element model predicts the biomechanical performance of cervical disc replacement and fusion hybrid surgery with various geometry of ball-and-socket artificial disc. Int J Comput Assist Radiol Surg 2017; 12:1399-409.
28. Li Y, Fogel GR, Liao Z, et al. Prosthesis and Hybrid Strategy Consideration for Treating 2-level Cervical Disc Degeneration in Hybrid Surgery. Spine (Phila Pa 1976) Mar 15 2018 43,6 379.
29. Li Y, Fogel GR, Liao Z, et al. Biomechanical Analysis of Two-level Cervical Disc Replacement with a Stand-alone U-shaped Disc Implant. Spine (Phila Pa 42,20, E1173, 2017.
30. Zhang, Z., H. Li, G. R. Fogel, Z. Liao, Y. Li and W. Liu (2017). "Biomechanical Analysis of Porous Additive Manufactured Cages for Lateral Lumbar Interbody Fusion: A Finite Element Analysis." World Neurosurgery June 2018 v114, e1120
31. Guy R Fogel MD, Laurence Rosen MD, Jayme Koltsov, Ph.D., Ivan Cheng MD Neurologic Adverse Event Avoidance in Lateral Lumbar Interbody Fusion: Technical Considerations Using Muscle Relaxants Journal of Spine Surgery July 2018
32. Biomechanical Analysis of Cortical Versus Pedicle Screw Fixation Stability in TLIF, PLIF, and XLIF Applications Edward K. Nomoto, MD, Guy R. Fogel, MD, Alexandre Rasouli, MD, Justin V. Bundy, MD, Alexander W. Turner, PhD Global Spine Journal Published July 31, 2018
33. Li Y, Fogel GR, Liao Z, et al. Prosthesis and Hybrid Strategy Consideration for Treating 2-level Cervical Disc Degeneration in Hybrid Surgery. Spine (Phila Pa 1976) 2017.
34. Li Y, Fogel GR, Liao Z, et al. Biomechanical Analysis of Two-level Cervical Disc Replacement with a Stand-alone U-shaped Disc Implant. Spine (Phila Pa 1976) 2017.
35. Book Chapter Complications and pitfalls in Posterior lumbar interbody fusion Brantigan and Fogel 2008.
36. Book Chapter Biomechanics of the Lateral Approach: Effects of Lumbar Spinal Instrumentation eXtreme Lateral Interbody Fusion (XLIF®) Guy R. Fogel, MD, FAAOS; G. Bryan Cornwall, PhD, PEng; Jeffrey D. Coe, MD; Alexander W.L. Turner, PhD: Second Edition: Editors J. Allan Goodrich, MD, FAAOS Orthopaedic Spine Surgeon, Champions Orthopaedic Group, Augusta, Georgia, Ildemaro J. Volcan, MD Clinical Associate Professor, Department of Neurosurgery, Georgia Health Sciences University; West Georgia Spine Specialists, LLC, Augusta, Georgia
37. Porous Additive Manufactured Cages Affect Biomechanical Performance After Transforaminal Lumbar Interbody Fusion
38. Zhenjun Zhang1, Guy R. Fogel2, Hangkai Shen1, Jia Zhu3, Zhenhua Liao3, Weiqiang Liu3
Zhang, Z., et al. (2018). "Biomechanical Analysis of Lateral Lumbar Interbody Fusion Constructs with Various Fixation Options: Based on a Validated Finite Element Model." World Neurosurg 114: e1120-e1129.
39. Zhang, Z., et al. (2018). "Biomechanical analysis of lumbar interbody fusion cages with various lordotic angles: a finite element study." Comput Methods Biomech Biomed Engin 21(3): 247-254.
40. Zhang, Z., et al. (2018). "Biomechanical evaluation of four surgical scenarios of lumbar fusion with hyperlordotic interbody cage: A finite element study." Biomed Mater Eng 29(4): 485-497
41. Zhang, Z., et al. (2018). "Biomechanical Analysis of Porous Additive Manufactured Cages for Lateral Lumbar Interbody Fusion: A Finite Element Analysis." World Neurosurg 111: e581-e591.
42. Zhang, Z., et al. (2018). "Finite element model predicts the biomechanical performance of transforaminal lumbar interbody fusion with various porous additive manufactured cages." Comput Biol Med 95: 167-174.
43. Guy Fogel MD, NicholasMartinMS et. al. Subsidence and fusion performance of a 3D-printed porous interbody cage with stress-optimized body lattice and microporous endplates - a comprehensive mechanical and biological analysis , https://doi.org/10.1016/j.spinee.2022.01.003