bluuebunny/crossref_metadata_2025 huggingface dataset:
A Comparison of the Anterior Approach and the Posterior Approach in Treating Multilevel Cervical Myelopathy
Authors: Chen Zihao , Liu Bin , Dong Jianwen , Feng Feng , Chen Ruiqiang , Xie Peigen , Rong Limin
Published: March 2018

Study Design:

A meta-analysis.

Objective:

To compare the effectiveness and the safety of the anterior approach with those of the posterior approach for patients diagnosed with multilevel cervical myelopathy (MCM).

Summary of Background Data:

Although many studies had compared the outcomes of the anterior approach with that of the posterior approach for MCM in recent years, choosing a proper surgical approach is still a controversial issue .

Methods:

We searched electronic databases for relevant studies that compared the anterior approach with the posterior approach for MCM. Then, data extraction and quality assessment were conducted. We used RevMan 5.3 for data analysis. A random effects model was used for heterogenous data, whereas a fixed-effects model was used for homogenous data.

Results:

A total of 25 nonrandomized controlled studies involving 1843 patients were included. No statistical difference was found with regard to the preoperative Japanese Orthopedic Association (JOA) score between the anterior group and the posterior group (P=0.08, 95% CI, −0.02 to 0.40). The postoperative JOA score and the recovery rate were higher in the anterior group as compared with the posterior group (P=0.02, 95% CI, 0.10–1.33; P=0.006, 95% CI, 2.33–13.90). In the subgroup analysis, better postoperative JOA scores and recovery rates were also obtained in the anterior group for cervical spondylotic myelopathy (P=0.0007, 95% CI, 0.29–1.09; P=0.01, 95% CI, 1.30–9.93). No significant differences were found in the complication rate, the revision rate, the operation time, and blood loss between the 2 groups (P=0.17, 95% CI, 0.89–1.95; P=0.21, 95% CI, 0.72–4.61; P=0.31, 95% CI, −20.20 to 63.30; P=0.88, 95% CI, −166.86 to 143.81).

Conclusions:

The anterior approach is associated with a better postoperative neurological outcome compared with the posterior approach in cervical spondylotic myelopathy patients. Considering the complication rate, the revision rate, the operation time, and blood loss, the anterior approach appears to be as safe as the posterior approach. Further randomized controlled trials comparing the anterior approach and the posterior approach for MCM should be performed to make a more convincing conclusion.
Radiologic Factors Associated With the Dynamic Change of Dural Sac Diameter in Lumbar Spine
Authors: Takahashi Shinji , Lord Elizabeth L. , Hayashi Tetsuo , Cohen Jeremiah R. , Lao Lifeng , Yao Qingqiang , Suzuki Akinobu , Nakamura Hiroaki , Wang Jeffrey C.
Published: March 2018

Study Design:

This is a cross-sectional radiologic study.

Objective:

The purpose of this study was to assess radiologic features related to dynamic changes of dural sac diameter using kinematic magnetic resonance imaging.

Summary of Background Data:

It is well known that the cross-sectional area of the lumbar spinal canal decreases during movement from flexion to extension. However, the radiologic characteristics related to dynamic changes of the lumbar spinal canal have not been elucidated.

Methods:

A total of 453 consecutive patients with clinically symptomatic low back pain or radiculopathy were recruited to undergo lumbar kinematic magnetic resonance imaging. The study participants consisted of 271 males (60%) and 182 females (40%). The average age was 44.5±12.2 years old. We investigated the following measurements at each level from L3–L4 to L5–S1: dural sac diameter, ligamentum flavum thickness, disk bulge, disk degeneration, angular motion, translational motion, and posterior disk height. The odds ratios (ORs) for ≥2 mm change of dural sac diameter between flexion and extension were calculated.

Results:

The average dural sac diameter was 12.2 mm in neutral, 12.5 mm in flexion, and 11.7 mm in extension, with an average difference between flexion and extension of 0.83 mm. The OR of a ≥2 mm change in L5–S1 was 0.55 as compared with L3–L4. Significantly increased ORs were observed with ≥3 mm of ligamentum flavum in neutral (OR: 4.05), 3–3.9 and ≥4 mm of disk bulge in neutral (ORs: 1.62 and 1.81, respectively), grade IV and V disk degeneration (OR: 2.59 and 2.86, respectively), ≥8 degrees of angular motion (OR: 1.81), and ≥2 mm of posterior disk height change (OR: 1.84).

Conclusions:

Several radiologic characteristics related to the dynamic change of dural sac diameter have been demonstrated.
Comparative Effectiveness of Treatments for Chronic Low Back Pain
Authors: Rihn Jeffrey A. , Radcliff Kristen , Norvell Daniel C. , Eastlack Robert , Phillips Frank M. , Berland Daniel , Sherry Ned , Freedman Mitchell , Vaccaro Alexander R.
Published: March 2018

Study Design:

A systematic review and network meta-analysis.

Objective:

To determine current treatment options of chronic low back pain (LBP) as defined by randomized controlled trials (RCTs) and to compare effectiveness of those treatments using a mixed-treatment comparison (MTC).

Summary of Background Data:

It is important to provide an evidence-based assessment of the treatment options that exist for LBP.

Methods:

A systematic search of RCTs was conducted in MEDLINE and the Cochrane Collaboration Library from 1990 to 2014. From the selected studies, we extracted preoperative and postoperative ODI and VAS back pain scores, additional surgeries, and complications. Standard and network meta-analytic techniques were used.

Results:

Twelve RCTs were included in the analysis: 5 total disk replacement (TDR) versus fusion; 1 TDR versus exercise and cognitive behavioral therapy (CBT); 5 fusion versus exercise and CBT; and 1 fusion versus physical therapy (PT). On the basis of MTC, with respect to ODI change scores, the pooled mean difference favoring fusion over exercise and CBT was 2.0 points (95% CI, −1.2 to 4.8). The pooled mean difference favoring TDR over exercise and CBT was 6.4 points (95% CI, 3.2–9.3). The pooled mean difference favoring fusion over PT was 8.8 points (95% CI, 4.1–13.6). The pooled mean differences favoring TDR over fusion was 4.4 points (95% CI, 2.37–6.63). For PT versus structured exercise with CBT, the pooled mean difference favoring exercise with CBT over PT was 6.8 points (95% CI, 1.5–12.8). For TDR versus PT, the pooled mean difference favoring TDR over PT was 13.2 points (95% CI, 8.0–18.4). Additional surgery rates were similar between treatment options.

Conclusions:

All 4 treatments provided some benefit to patients with chronic LBP. According to the MTC analysis, TDR may be the most effective treatment and PT the least effective treatment for chronic LBP. This review is based on a limited number of RCT studies and does not support any 1 treatment modality for all patients.
All-Pedicle Screw Fixation With 6-mm-Diameter Cobalt-Chromium Rods Provides Optimized Sagittal Correction of Adolescent Idiopathic Scoliosis
Authors: Lamerain Mayalen , Bachy Manon , Dubory Arnaud , Kabbaj Reda , Scemama Caroline , Vialle Raphaël
Published: March 2018

Purpose:

Recently introduced cobalt-chromium (CoCr) rods that rely solely on pedicle screws produce very good results in correcting scoliotic curves. All-pedicle screws constructs are also suspected of decreasing thoracic kyphosis. The current study was designed to evaluate sagittal correction in adolescent idiopathic scoliosis patients, using 6-mm CoCr rods and all-screw constructs.

Materials and Methods:

A total of 61 patients treated by posterior spinal fusion and instrumentation, using all-pedicle screw constructs were included. The mean age at surgery was 15.4 years (range, 12–18 y). Forty-five patients (group A) were diagnosed with decreased thoracic kyphosis, and 16 patients (group B) had normal (35–50 degrees) thoracic kyphosis.

Results:

The preoperative main Cobb angle was 62.93±19.38 degrees in group A and 73.45±22.13 degrees in group B. In group A, the postoperative main Cobb angle was 23.33±12.71 degrees. In group B, the postoperative main Cobb angle was 27.20±10.04 degrees. The T4–T12 thoracic kyphosis improved postoperatively from 18.15±10.29 to 28.18±8.35 degrees in group A. In group B, the postoperative T4–T12 thoracic kyphosis was 40.34±3.13 degrees. Statistical analysis showed a significant improvement between preoperative and postoperative values of T4–T12 thoracic kyphosis in group A. In group B, the differences in T4–T12 thoracic kyphosis values were not statistically significant.

Conclusions:

Our result demonstrates a significant improvement of T4–T12 thoracic kyphosis in the hypokyphotic group of patients and confirms that CoCr rods can produce sagittal corrections in hypokyphotic adolescent idiopathic scoliosis patients. Our results confirm the benefit of combining all-pedicle screw constructs with a posterolateral translational in situ bending procedure to correct hypokyphosis directly.
Minimally Invasive Cervical Pedicle Screw Fixation by a Posterolateral Approach for Acute Cervical Injury
Authors: Komatsubara Tadashi , Tokioka Takamitsu , Sugimoto Yoshihisa , Ozaki Toshifumi
Published: March 2018

Study Design:

This is a retrospective case series.

Objective:

To avoid lateral misplacement of midcervical pedicle screws, T.T., one of our authors, developed a method for minimally invasive cervical pedicle screw (MICEPS) fixation by a posterolateral approach. We reviewed our initial experience with this fixation for trauma cases.

Summary of Background Data:

Excellent clinical results with cervical screws have been reported for trauma cases. Although cervical pedicle screw fixation can be an essential part of reconstruction in spinal disorders, there is also a risk for injury to the vertebral artery.

Methods:

This study included 56 consecutive patients who received surgery for cervical fractures. We inserted a total of 203 cervical pedicle screws. Nineteen patients were treated by conventional methods. Thirty-seven patients were treated by MICEPS fixation. According to the MICEPS fixation, 12 patients were treated by unilateral fusion, 25 patients by bilateral fusion. All pedicle screws were inserted using spinal navigation system in the both groups.

Results:

The average surgical time was 217 minutes with the conventional pedicle screw fixation and 165 minutes with the MICEPS fixation (P=0.0014). The average intraoperative bleeding was 560 mL in the conventional fixation and 140 mL in the MICEPS fixation (P<0.0001). Clinically significant screw deviation was significantly lower in the MICEPS fixation group than in the conventional cervical pedicle screw group (P=0.0039). There was not any deep wound infection in both groups.

Conclusions:

This intramuscular approach allows for horizontal pedicle screw insertion. This technique is probably useful for reducing intraoperative bleeding. In this study, incidence of screw perforation was significantly lower in the MICEPS fixation group than in the conventional cervical pedicle screw group. In particular, neither of the misplaced screws was laterally deviated in the MICEPS group.
Effect of Drugs Associated With Bleeding Tendency on the Complications and Outcomes of Transforaminal Epidural Steroid Injection
Authors: Park Tae Keun , Shin Sung Joon , Lee Jae Hyup
Published: March 2018

Study Design:

This is a retrospective case-control study.

Objective:

To evaluate the influence of medication-related bleeding tendency on the clinical outcomes and complications of transforaminal epidural steroid injection (TFESI).

Summary of Background Data:

TFESI may result in serious complications such as epidural hematoma or adhesions in patients with medication-related bleeding tendency. However, little is known about the true relationship between medication-related bleeding tendency and postprocedural complications.

Methods:

Retrospective review of the medical records of patients who had TFESI from 2010 to 2014 was done. Commonly used medications such as warfarin, heparin, aspirin, clopidogrel, and Opalmon (limaprost alfadex) were included as medications associated with bleeding tendency. Patients were divided into 3 groups and the treatment outcomes for each group were compared: The first group used medications associated with bleeding tendency, but discontinued them in due time before the procedure (discontinued group). The second group used medications associated with bleeding tendency and continued receiving medication (continuing group). The third group did not use any medications associated with a bleeding tendency (nonmedicated group).

Results:

Among 2,469 patients, 1,234 were in the discontinued group, 408 patients in the continuing group, and 827 patients in the nonmedicated group. There were no statistically significant differences between groups for the treatment outcomes such as the degree of pain relief, duration of improvement, and complication rates including symptomatic epidural hematoma. Moreover, for the discontinued group and continuing group, the treatment outcomes were compared among patients with same medication, and revealed no differences.

Conclusions:

This study demonstrated that continued use of medications associated with bleeding tendency does not increase epidural hematoma or symptomatic exacerbation, and thus should not be considered as a contraindication for TFESI.

Level of Evidence:

Level 3.
Morphologic Evaluation of Lumbosacral Nerve Roots in the Vertebral Foramen
Authors: Morishita Yuichiro , Masuda Muneaki , Maeda Takeshi , Ueta Takayoshi , Shiba Keiichiro
Published: March 2018

Study Design:

The prospective cohort study.

Objective of the Study:

The objective was to evaluate the relationships between local pressure changes of the intervertebral foramen during lumbar spine extension and lumbar foraminal morphology.

Summary of Background Data:

The physiological states of lumbosacral nerve roots in the vertebral foramen remain controversial.

Methods:

We evaluated 56 lumbosacral vertebral foramens in 21 patients with L4-degenerative spondylolisthesis. All patients underwent L4-5 posterolateral fusion (PLF). The local pressure of the intervertebral foramen was measured intraoperatively, and measurement was performed before and after L4-5 PLF. We defined the changes in the ratio of local pressure between lumbar flexion to extension as percent pressure. The sagittal angular motion, distance between the inferior cortex of the cranial pedicle and superior cortex of the caudal pedicle, posterosuperior margin of the superior vertebral body and superior articular facet, posteroinferior edge of the superior vertebral body and inferior articular facet, and the intervertebral disc height were measured using preoperative functional plain radiographs and CT images.

Results:

The average local pressure of the intervertebral foramen significantly increased during lumbar extension. However, the L4-5 vertebral foraminal pressure after PLF were nearly identical. There was no significant correlation between percent pressure and lumbar range of motion. Furthermore, there were no significant correlations between percent pressure and each morphologic parameter of the lumbar foramen.

Conclusions:

There were no significant relationships between the lumbar foraminal morphology and intervertebral foraminal pressure changes during lumbar extension, and L4-5 vertebral foraminal pressure was not affected by the lumbar posture after L4-5 posterior fusion. On the basis of the results, the external dynamic stresses on the nerve roots in the vertebral foramen might be improved by lumbar posterior fusion using instrumentation without direct decompression of the vertebral foramen.
Posterior or Single-stage Combined Anterior and Posterior Approach Decompression for Treating Complex Cervical Spondylotic Myelopathy Coincident Multilevel Anterior and Posterior Compression
Authors: Zhou Xiaoxiao , Cai Pan , Li Yuwei , Wang Haijiao , Xia Shengli , Wang Xiuhui
Published: March 2018

Study Design:

A single-center, retrospective, longitudinal matched cohort clinical study of prospectively collected outcomes.

Objective:

To compare retrospectively the clinical outcomes and complications of the posterior approach laminoplasty and single-stage anterior approach laminoplasty combined with anterior cervical corpectomy and fusion and anterior cervical discectomy and fusion for treating patients with cervical spondylotic myelopathy coincident multilevel anterior and posterior compression, known as complex cervical spondylotic myelopathy (cCSM) here.

Summary of Background Data:

The optimal surgical management of this type of cCSM remains controversial.

Methods:

Sixty-seven patients with multilevel cCSM underwent decompression surgery from 1996 to 2007. Among these patients, 31 underwent a single-stage combined approach with decompression (combined approach group) and 36 underwent laminoplasty for posterior approach (posterior approach group). Average operative duration, operative estimated blood loss, surgical costs, and cervical alignment were measured.

Results:

Average operative duration, operative estimated blood loss, and surgical costs were significantly lower in the posterior approach group than those in the combined approach group (P<0.001). Visual analog scale and modified Japanese Orthopedic Association scale were insignificantly different at each data collection period (P>0.05). No statistical difference was observed in the preoperative Cobb angle (P>0.05), whereas a significant statistical difference was observed for the postoperative Cobb angle (P<0.05) and variation of Cobb angle (P<0.05) between the 2 groups. The surgical incidences of complications were 22.2% and 48.4% in the posterior and combined approach groups (P<0.05), respectively.

Conclusions:

For treating multilevel cCSM, both the posterior approach laminoplasty and single-stage combined approach led to significant neurological improvement and pain reduction in the majority of patients. Both approaches showed similar results in terms of decompression and neurological improvement. The posterior approach was superior to the combined approach in terms of surgical costs, surgical time, blood loss, and complication rate.
Adjacent Segment Disease in the Cervical and Lumbar Spine
Authors: Tobert Daniel G. , Antoci Valentin , Patel Shaun P. , Saadat Ehsan , Bono Christopher M.
Published: March 2018

Adjacent segment disease (ASD) is disappointing long-term outcome for both the patient and clinician. In contrast to adjacent segment degeneration, which is a common radiographic finding, ASD is less common. The incidence of ASD in both the cervical and lumbar spine is between 2% and 4% per year, and ASD is a significant contributor to reoperation rates after spinal arthrodesis. The etiology of ASD is multifactorial, stemming from existing spondylosis at adjacent levels, predisposed risk to degenerative changes, and altered biomechanical forces near a previous fusion site. Numerous studies have sought to identify both patient and surgical risk factors for ASD, but a consistent, sole predictor has yet to be found. Spinal arthroplasty techniques seek to preserve physiological biomechanics, thereby minimizing the risk of ASD, and long-term clinical outcome studies will help quantify its efficacy. Treatment strategies for ASD are initially nonoperative, provided a progressive neurological deficit is not present. The spine surgeon is afforded many surgical strategies once operative treatment is elected. The goal of this manuscript is to consider the etiologies of ASD, review its manifestations, and offer an approach to treatment.
The Minimally Important Clinical Difference
Authors: Maltenfort Mitchell G.
Published: March 2018

The minimally important clinical difference (MCID) is the smallest measureable change in outcome score that will make a difference to the patient. MCID is usually estimated either as the smallest difference that can be detected statistically, or as the difference between patients who respond positively and negatively to an anchor question.

• MCID is the least a surgeon can do which benefits the patient from the patient’s perspective.

• MCID is necessary information in power analyses used to design new studies comparing treatments.
Predictive Factors of the Effectiveness of Caudal Epidural Steroid Injections in Managing Patients With Chronic Low Back Pain and Radiculopathy
Authors: Billy Gregory G. , Lin Ji , Gao Mengzhao , Chow Mosuk X.
Published: March 2018

Study Design:

Retrospective clinical outcome analysis.

Objective:

To evaluate and determine whether demographic, comorbid factors, or physical examination findings may predict the outcome of caudal epidural steroid injections in managing patients with chronic low back pain and radiculopathy

Summary of Background Data:

The caudal epidural approach is commonly utilized with patients who are on anticoagulation or who have had prior lumbar surgery to treat L5 or S1 radiculopathies.

Methods:

A retrospective review of 136 patients undergoing an initial caudal epidural steroid injection for radiculopathy from January 1, 2006 to August 30, 2013. The patients were assessed before their injections for their pain levels: visual analog scale, presence of lumbar paraspinal and sciatic notch sensitivity, pain with provocative maneuvers, motor weakness, and sensory loss. The patients were then reassessed following their injection for their visual analog scale pain levels, percentage improvement, and duration of pain relief.

Results:

Stepwise regression was used to determine whether demographic, comorbid factors, or physical examination signs were predictive of percentage improvement or length of relief following an injection. Among these variables, duration of symptoms was found to be negatively significantly related with a P-value of 0.032 for percentage of improvement. For each week of the duration of symptoms, the percentage of improvement decreased by 0.07%. Regarding physical examination findings, presence of pain with lumbar extension was negatively and significantly related to length of relief duration with a P-value of 0.0124. The mean length of relief duration is 38.37 weeks for individuals without painful lumbar extension and 14.68 weeks for individuals with painful lumbar extension

Conclusions:

The mean length of relief following a caudal injection is reduced by 62% in patients who exhibit pain with lumbar extension.
Lumbar Spinal Surgery in Patients With Parkinson Disease
Authors: Kimura Hiroaki , Fujibayashi Shunsuke , Otsuki Bungo , Takemoto Mitsuru , Shikata Jitsuhiko , Odate Seiichi , Matsushita Mutsumi , Kusuba Akira , Kim Youngwoo , Sakamoto Takeshi , Watanabe Kei , Ota Masato , Izeki Masanori , Tsubouchi Naoya , Matsuda Shuichi
Published: March 2018

Study Design:

A multicenter, retrospective study.

Objective:

To identify the factors that affect surgery-related complications and to clarify the surgical strategy for treating lumbar disorders in Parkinson disease (PD).

Summary of Background Data:

Previous studies have reported a high complication rate for spinal surgery in patients with PD. Because of the limited number of studies, there are no guidelines for spinal surgery for PD patients.

Methods:

We retrospectively reviewed the records for 67 PD patients who underwent lumbar spinal surgery. The patients were divided into 3 groups: 12 patients underwent laminectomy (Laminectomy), 24 underwent fusion surgery (Fusion) for lumbar canal stenosis, and 31 underwent corrective surgery for spinal deformity (Deformity). We assessed surgery-related complications in each group. The Cox proportional hazards model was used to identify the factors that predicted surgical failure.

Results:

The percentages of patients who experienced failure of the initial surgery were 33.3% in the Laminectomy group, 45.8% in the Fusion group, and 67.7% in the Deformity group. The rates of implant failure were high in the Fusion and Deformity groups (33.3% and 38.7%, respectively). The Deformity group had a high rate of postoperative fracture (41.9%). These complications occurred at the most caudal site within a year after surgery and resulted in progression of kyphotic deformity. Multivariate analysis revealed that preoperative lumbar lordosis angle (LL) (per −1 degree) was associated with a failure of the initial surgery (hazard ratio, 1.024; 95% confidence interval, 1.008–1.04; P=0.003).

Conclusions:

We have demonstrated that a small preoperative LL increases the risk for failure of the initial surgery. Attaining and maintaining the proper lumbar lordosis with rigid fixation may be necessary in PD patients with a small preoperative LL.
Prospective Cohort Study of Performance Status and Activities of Daily Living After Surgery for Spinal Metastasis
Authors: Kakutani Kenichiro , Sakai Yoshitada , Maeno Koichiro , Takada Toru , Yurube Takashi , Kurakawa Takuto , Miyazaki Shingo , Terashima Yoshiki , Ito Masaaki , Hara Hitomi , Kawamoto Teruya , Ejima Yasuo , Sakashita Akihiro , Kiyota Naomi , Kizawa Yoshiyuki , Sasaki Ryohei , Akisue Toshihro , Minami Hironobu , Kuroda Ryosuke , Kurosaka Masahiro , Nishida Kotaro
Published: March 2018

Study Design:

A prospective cohort study of performance status (PS) and activities of daily living (ADL) in patients with spinal metastasis.

Objective:

To identify the effect of spinal surgery on PS and ADL in patients with spinal metastasis.

Summary of Background Data:

Spinal metastasis causes severe neurological deficits, resulting in drastic loss of patients’ PS and ADL. However, the effect of spine surgery on PS and ADL is not well known.

Materials and Methods:

Seventy patients with spinal metastasis were enrolled in this study. Forty-six patients desired and underwent spine surgery (“surgery” group) and 24 patients did not desire surgery (“nonsurgery” group). Both groups received optimal treatments, including radiation, chemotherapy, and palliative care services. Evaluation was performed at 1, 3, and 6 months after study enrollment using the Eastern Cooperative Oncology Group PS, the Barthel index (BI) for ADL, and Frankel classification for neurological status.

Results:

There was no significant difference in baseline PS, the BI, or Frankel classification between the groups. The surgery group showed significant improvement in PS, maintaining grade 2 or less throughout the duration of the study, as well as in ADL, exceeding 70 points of the BI, compared with the nonsurgery group (P<0.05). Significantly improved neurological condition was also observed in the surgery group over the following 6 months. More than 95% of patients who underwent surgery improved their PS, the BI, and neurological status. Furthermore, >80% of these patients maintained improvement in PS, the BI, and neurological status for at least 6 months. In contrast, PS, the BI, and neurological status of patients in the “nonsurgery” group deteriorated throughout the study period.

Conclusions:

Spine surgery improves PS, ADL, and neurological status in patients with spinal metastasis for a minimum 6 months. This indicates that these patients can acquire an independent daily life.
A Novel Groove-Entry Technique for Inserting Thoracic Percutaneous Pedicle Screws
Authors: Ishii Ken , Shiono Yuta , Funao Haruki , Singh Kern , Matsumoto Morio
Published: March 2018

Study Design:

Surgical technique.

Objective:

To evaluate the efficacy of a novel groove-entry technique for thoracic percutaneous pedicle screw (PPS) insertion.

Summary of Background Data:

Minimally invasive spine stabilization (MISt) using posterior thoracolumbar instrumentation has many advantages over open procedures. Because of the variability among PPS entry points, the sloped cortex of the transverse process, and the narrow thoracic pedicle, thoracic PPS placement is technically challenging.

Materials and Methods:

A retrospective review of 24 patients who underwent minimally invasive spine stabilization procedures involving 165 thoracic PPS placements using the novel technique was performed. The thoracic PPS entry is a groove formed by 3 bony elements: the cranial portion of the base of the transverse process, the rib neck, and the posterolateral wall of the pedicle. This groove can be easily identified under fluoroscopy with a Jamshidi needle allowing thoracic PPS insertion in the craniocaudal direction.

Results:

Of the 165 thoracic PPSs placed, “Good” or “Acceptable” PPS placement accuracy was achieved in 152 (92.1%) and 164 (99.4%) placements, respectively. No complications such as organ injury, and screw loosening or breakage were observed with thoracic PPS insertion.

Conclusions:

This novel technique is both safe and reliable, with low misplacement and complication rates. In hospitals in which computer image guidance or navigation is unavailable, this groove-entry technique may become the standard for thoracic PPS insertion.
Sagittal Vertical Axias, Spinosacral Angle, Spinopelvic Angle, and T1 Pelvic Angle
Authors: Zhang Yun-peng , Qian Bang-ping , Qiu Yong , Qu Zhe , Mao Sai-hu , Jiang Jun , Zhu Ze-zhang
Published: March 2018

Study Design:

This is a retrospective study.

Objective:

To identify the relationship between global sagittal alignment and health-related quality of life (HRQoL) in ankylosing spondylitis (AS) patients with thoracolumbar kyphosis.

Summary of Background Data:

Little data are available on correlation between global sagittal alignment and HRQoL in AS.

Materials and Methods:

A total of 107 AS patients were included in this study. The radiographic parameters were measured on lateral radiographs of the whole spine, including sagittal vertical axias (SVA), spinosacral angle (SSA), spinopelvic angle (SPA), and T1 pelvic angle (TPA). HRQoL was assessed using the oswestry disability index questionnaire, the bath ankylosing spondylitis disease activity index, the bath ankylosing spondylitis functional index, and short form-36 questionnaire. The patients were divided into 2 groups: group A (n=76, global kyphosis≤70 degrees), group B (n=31, global kyphosis>70 degrees). Statistical analysis was performed to identify significant differences between these 2 groups. In addition, correlation analysis and multiple regression analysis between radiologic parameters and clinical questionnaires were conducted.

Results:

With respect to SVA, SSA, SPA, TPA, and HRQoL scores, significant differences were observed between 2 groups (P<0.05). Also, SVA, SSA, SPA, and TPA were significantly related to HRQoL. Multiple regression analysis revealed that SVA, SSA, SPA, and TPA were significant parameters in the prediction of HRQoL in AS patients with thoracolumbar kyphosis. Of note, HRQoL related much more to SSA and SPA than SVA and TPA.

Conclusions:

AS patients with moderate and severe deformity were demonstrated to be significantly different in terms of SVA, SSA, SPA, TPA, and HRQoL. Moreover, SVA, SSA, SPA, and TPA correlated with HRQoL significantly. In particular, SSA and SPA could better predict HRQoL than SVA and TPA in AS patients with thoracolumbar kyphosis.
Preoperative Mental Health is not Predictive of Patient-reported Outcomes Following a Minimally Invasive Lumbar Discectomy
Authors: Mayo Benjamin C. , Massel Dustin H. , Bohl Daniel D. , Long William W. , Modi Krishna D. , Narain Ankur S. , Hijji Fady Y. , Lopez Gregory , Singh Kern
Published: March 2018

Study Design:

This is a retrospective cohort study.

Objective:

To determine if preoperative mental health is associated with patient-reported outcomes (PROs) following a minimally invasive lumbar discectomy.

Summary of Background Data:

PROs are commonly used to quantify a patient’s perceived health status. Recently, mental health has been theorized to directly affect patients’ perception of their disability and pain after spine surgery.

Materials and Methods:

A registry of patients who underwent a primary, single-level minimally invasive lumbar discectomy was reviewed. The association between preoperative Short-Form Health Survey mental composite score (MCS) and change in PROs [Oswestry Disability Index, back and leg visual analog scale (VAS) pain scores] from preoperative to postoperative (6-week, 12-week, 6-month) timepoints was assessed using multivariate regression controlling for patient demographics and the respective preoperative PRO. Patients in the top and bottom quartiles of preoperative MCS were compared regarding achievement of minimum clinically important difference for each PRO.

Results:

A total of 110 patients were included in the analysis. Better preoperative mental health was associated with lower preoperative disability and decreased preoperative back VAS (P<0.05 for each). Higher preoperative MCS was also associated with greater improvements in back VAS at 6-weeks postoperatively (P<0.05). There was no association between preoperative MCS and change in any PROs at the 12-week or 6-month postoperative visits. Patients in the bottom quartile of preoperative MCS achieved minimum clinically important difference in all PROs at similar rates to patients in the top quartile of preoperative MCS.

Conclusions:

Patients with better preoperative mental health scores are more likely to report decreased disability and pain preoperatively. However, preoperative mental health was not predictive of changes in long-term disability or pain. As a result, patients with a wide range of preoperative mental health scores can achieve satisfactory long-term reductions in disability and pain levels after a lumbar discectomy.

Level of Evidence:

Level IV.
Intradural Intramedullary Cervicothoracic Tumor With Long-Segmental Localization
Authors: Hasturk Askin E. , Etikcan Teoman , Canbay Suat
Published: March 2018

Ependymomas are the most common gliomas of the conus and lower cord, with the cervical cord being the second most common location. These tumors can extend upward 3–4 vertebra, and some ependymomas can extend up over 15 segments. Depending on many factors, such as tumor size, lateralization, kyphotic deformity, and lordosis state, there are several posterior surgical options, including laminectomy, laminectomy and lateral mass screw-plate, and laminoplasty. In this study, we discuss a case of intradural intramedullary cervicothoracic ependymoma with long-segmental localization, as well as the general surgical principles of its excision with step-by-step demonstrative figures.
Three-dimensional Cross-Platform Planning for Complex Spinal Procedures
Authors: Kosterhon Michael , Gutenberg Angelika , Kantelhardt Sven R. , Conrad Jens , Nimer Amr Amr , Gawehn Joachim , Giese Alf
Published: March 2018

Study Design:

A feasibility study.

Objective:

To develop a method based on the DICOM standard which transfers complex 3-dimensional (3D) trajectories and objects from external planning software to any navigation system for planning and intraoperative guidance of complex spinal procedures.

Summary of Background Data:

There have been many reports about navigation systems with embedded planning solutions but only few on how to transfer planning data generated in external software.

Materials and Methods:

Patients computerized tomography and/or magnetic resonance volume data sets of the affected spinal segments were imported to Amira software, reconstructed to 3D images and fused with magnetic resonance data for soft-tissue visualization, resulting in a virtual patient model. Objects needed for surgical plans or surgical procedures such as trajectories, implants or surgical instruments were either digitally constructed or computerized tomography scanned and virtually positioned within the 3D model as required. As crucial step of this method these objects were fused with the patient’s original diagnostic image data, resulting in a single DICOM sequence, containing all preplanned information necessary for the operation. By this step it was possible to import complex surgical plans into any navigation system.

Results:

We applied this method not only to intraoperatively adjustable implants and objects under experimental settings, but also planned and successfully performed surgical procedures, such as the percutaneous lateral approach to the lumbar spine following preplanned trajectories and a thoracic tumor resection including intervertebral body replacement using an optical navigation system. To demonstrate the versatility and compatibility of the method with an entirely different navigation system, virtually preplanned lumbar transpedicular screw placement was performed with a robotic guidance system.

Conclusions:

The presented method not only allows virtual planning of complex surgical procedures, but to export objects and surgical plans to any navigation or guidance system able to read DICOM data sets, expanding the possibilities of embedded planning software.
A New Method of Measuring the Occipitocervical Angle That Could be Applied as an Intraoperative Indicator During Occipitocervical Fusion
Authors: Nagashima Shingo , Nagae Masateru , Arai Yuji , Tonomura Hitoshi , Takatori Ryota , Sukenari Tsuyoshi , Fujiwara Hiroyoshi , Sawada Koshiro , Mikami Yasuo , Kubo Toshikazu
Published: March 2018

Study Design:

A method for measuring occipitocervical angle.

Objective:

To develop a new method of measurement for assessing the occipitocervical angle using intraoperative fluoroscopic imaging, and to examine its reliability.

Summary of Background Data:

To avoid postoperative complications following occipitocervical fusion, it is vital to obtain a suitable fusion angle between the occipital bone and the upper cervical spine.

Materials and Methods:

The subjects were 30 cases with occipito-atlanto-axial lesions and 30 healthy volunteers. Lateral plain radiographs of the cervical spine in neutral position were used to draw the McGregor line, the line between the external occipital protuberance and the most caudal point on the midline occipital curve (Oc line), the tangential line of the inferior endplate of the C2 vertebra (C2 line), and the posterior longitudinal line of the C2 vertebra (Ax line). The angles formed by these 4 lines and the horizontal line were measured. The O-C2 angle and the Oc-Ax angle, the new indicator, were measured by 3 doctors and reliability was evaluated.

Results:

In the disease group, mean intraobserver variances of the McGregor, Oc, C2, Ax, O-C2, and Oc-Ax angles were 0.7, 1.3, 1.5, 1.2, 1.6, and 1.9 degrees. Mean intraobserver intraclass correlation coefficients were 0.997, 0.994, 0.994, 0.997, 0.989, and 0.988, showing high intraobserver reliability for all angles. Mean interobserver intraclass correlation coefficients were 0.998, 0.996, 0.994, 0.997, 0.988, and 0.990, showing high interobserver reliability for all angles. The same reliability was obtained in the healthy group.

Conclusions:

The Oc-Ax angle is as reliable an indicator as the conventional O-C2 angle, and could be used as a new intraoperative indicator for occipitocervical fusion. It may be particularly useful in cases where it is difficult to identify the McGregor line and/or the inferior endplate of the C2 vertebra.

Level of Evidence:

Level 3—diagnostic study.
Assessment of the Cross-Sectional Areas of the Psoas Major and Multifidus Muscles in Patients With Adult Spinal Deformity
Authors: Banno Tomohiro , Yamato Yu , Hasegawa Tomohiko , Kobayashi Sho , Togawa Daisuke , Oe Shin , Mihara Yuki , Kurosu Kenta , Yamamoto Naoto , Matsuyama Yukihiro
Published: March 2018

Study Design:

This is a case-control study.

Objective:

The present study aimed to compare the cross-sectional areas of the psoas major and multifidus muscles between elderly patients with adult spinal deformity (ASD) and age-matched and body weight–matched controls, and to evaluate the associations between the cross-sectional areas of these muscles and the severity of spinal deformity.

Summary of Background Data:

The study included 49 female kyphosis patients with mild scoliosis (Cobb angle <20 degrees; mean age, 70.9 y, group D). The control group (group C) included age-matched and body weight–matched female patients who underwent abdominal surgery (n=98; mean age, 71.7 y).

Materials and Methods:

The cross-sectional areas of the bilateral psoas majors and multifidus muscles were calculated using preoperative L4/L5 axial computed tomography images. In group D, the following spinopelvic parameters were assessed: sagittal vertical axis, pelvic tilt, pelvic incidence, lumbar lordosis, and thoracic kyphosis. The relationships between the muscle cross-sectional areas and spinopelvic parameters were evaluated.

Results:

The cross-sectional area of the multifidus muscle was lower in group D than in group C. However, the cross-sectional area of the psoas major muscle was not different between the 2 groups. In multiple regression analysis, the cross-sectional area of the multifidus muscle was significantly associated with all spinopelvic parameters.

Conclusions:

The cross-sectional area of the multifidus muscle might be lower in elderly patients with ASD than in controls. In the elderly population, the severity of sagittal spinal deformity might be correlated with the cross-sectional area of the multifidus muscle. Therefore, muscle imbalances between the flexors and extensors of the spine could participate in the pathology of ASD.
Fluoroscopic Confirmation of Sacral Pedicle Screw Placement Utilizing Pelvic Inlet and Outlet Technique
Authors: Ghobrial George M. , Al-Saiegh Fadi , Franco Daniel , Heller Joshua
Published: March 2018

Minimally invasive surgical techniques may decrease length of stay, operative duration and blood loss, and postoperative pain. Numerous technical challenges and concerns surround the placement of percutaneous pedicle screws at the lumbosacral level. Maximization of screw triangulation, bicortical purchase, and rostral bias toward the sacral promontory has been shown repeatedly to stabilize lumbosacral segment instrumentation and maximize pullout strength. Because of the unique anatomy, conventional anteroposterior (AP) and lateral radiographic views are relatively less reliable at determining screw depth and penetration of the sacral cortex. Percutaneous sacral pedicle fixation using AP and lateral 2-dimensional fluoroscopy is complicated by the variable contour of the sacral alae and promontory. The pelvic inlet view is ideal for visualization of the ventral screw extent and is obtained by directing 45-degree cephalad and 0-degree mediolateral, with adjustments aligning the patient’s pelvic brim. The modified pelvic outlet view is obtained with the trajectory axis being directed 45-degree caudal from the AP plane. This aligns the pubic symphysis with the second sacral vertebrae providing visualization of the superior boundary of the S1-bony neural foramen and any inferior wall pedicle breaches. The authors describe this reliable fluoroscopic technique and their clinical experience with percutaneous S1-screw placement.
Treatment of Spinal Tumors in a High Volume Center has Direct Impact on Local Recurrence, Morbidity, and Mortality
Authors: Lador Ran , Bandiera Stefano , Gasbarrini Alessandro , Ghermandi Riccardo , Boriani Stefano
Published: March 2018

Objective of the Study:

En bloc resections of spine tumors aim at locally controlling the disease for both improving the patient’s quality of life as well as improving mortality. The purpose of this study was to compare the outcome between patients who were initially treated in a high volume specialized center, and patients who initially underwent either invasive diagnostic procedure or an initial surgical attempt to treat the disease in a different center.

Materials and Methods:

A retrospective study of 1681 patients affected by spine tumors—treated from 1990 to 2015 by the same team.

Results:

A total of 220 en bloc resections that were performed on 216 patients during that period. Most of the tumors were primary—165 cases (43 benign and 122 malignant), metastases occurred in 55 cases. One hundred sixty-eight patients (77.8%) were solely treated in the institute and were considered noncontaminated cases (NCCs) and 48 (22.2%) were previously treated elsewhere and were considered contaminated cases (CCs). Median follow-up was 45 months (0–371).

Thirty-three local recurrences (15.28%) were recorded. Fourteen patients (29.17%) from the CC and 19 (11.31%) from the NCC group.

A total of 153 complications were observed in 100 out of 216 patients (46.2%). Sixty-four of these patients (30%) suffered 1 complication, while the rest had 2 or more. Twenty-eight (58%) of the CC group and 72 (42.85%) of the NCC group, had at least 1 complication.

Sixty patients died as a result of the disease during the follow-up period. Twenty-one (43.75%) and 39 (23.21%) patients died in the CC and NCC cohorts, respectively.

CC, surgical margins of the resected tumor—intralesional, marginal, and malignant tumors, were statistically significant independent risk factors for local recurrence of the tumor. Contamination, local recurrence, neoadjuvant radiotherapy, the number of level resected, and metastatic tumors compared with primary malignant tumor, were shown to be independent risk factors for patient’s death.

Conclusions:

It is apparent that there is a substantial added risk in performing either invasive diagnostic procedures or attempting a surgical resection of the tumor in a nonspecialized center. This risk includes both higher recurrences of the tumor as well as increased mortality. It is therefore reasonable to conclude that the whole treatment, from biopsy to resection, should be performed in the same center, and this center should be a high volume, specialized in treating these type of spine pathologies.

The surgeon who treats the patient first has a great responsibility, as it is the first treatment that most affects prognosis. To reduce the chance of local recurrence, morbidity, and mortality, all invasive diagnosis and treatment, should be performed by an experienced team, as the consequences are dramatic.
Incidence and Factors Predictive of Dysphagia and Dysphonia After Anterior Operation With Multilevel Cervical Spondylotic Myelopathy
Authors: Yu Shunzhi , Chen Zhi , Yan Ning , Hou Tiesheng , He Shisheng
Published: March 2018

Study Design:

Retrospective database analysis.

Objective of the Study:

The objective of the study was to quantify the incidence of dysphagia and dysphonia and assess the associated risk factors after multilevel cervical anterior operation.

Summary of Background Data:

Anterior approach for multilevel cervical spondylotic myelopathy has been developed and obtained favorable outcomes. As number of fused levels increased, the operation difficulty, invasiveness and operative risks are higher. Meanwhile, the 2 most common postoperative complications described in the literature are dysphonia and dysphagia.

Materials and Methods:

Two hundred thirty-six multilevel cervical spondylotic myelopathy patients between October 2004 and June 2012 were included in the study. All patients undergoing anterior operation, and incidences of dysphagia were identified. Risk factors were assessed using logistic regression.

Results:

At a minimum of 1 year after operation, 70.6% (n=156) were 3-level anterior operation and 29.4% (n=65) were 4-level anterior operation. The overall dysphagia rate was 23.1% (51 patients). The overall dysphonia rate was 28.5% (63 patients). Logistic regression analysis demonstrated that risk factors for dysphagia included age, operation time and lack of tracheal traction exercise. Age, operation time were 2 factors significantly related to dysphonia.

Conclusions:

The incidence of postoperative dysphagia and dysphonia is relative higher after multilevel anterior operation. Age and operation time carry a greater risk of postoperative dysphagia and dysphonia. Tracheal traction exercise might help patients reduce postoperative dysphagia. Sufficient preoperative preparation and evaluation combining with proficient and precise operation technique are suggested when multilevel anterior fusion is performed.