bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Timing of Surgery and Symptom Resolution in Patients Undergoing Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disk Disease and Radiculopathy
Authors: Villavicencio Alan T. , Nelson E. Lee , Rajpal Sharad , Burneikiene Sigita 
Published: March 2018

Objective:
Success rates of surgical interventions for lumbar disorders vary significantly depending on multiple factors and, among them, the duration of symptoms. It is not clear whether there is a “cutoff” time when decompression and fusion surgery becomes less effective in the conditions with chronic nerve root compression symptomatology. The main objective of this study was to analyze whether duration of symptoms has any effect on clinical outcomes and primarily resolution of radicular pain symptoms due to degenerative disk disease and stenosis with spondylolisthesis in patients undergoing transforaminal lumbar interbody fusion (TLIF).

Methods:
The prospective observational study was performed. Eighty-four patients with radicular symptoms due to degenerative disk disease and stenosis with spondylolisthesis with no previous fusion surgeries and undergoing 1- to 3-level TLIF surgery were enrolled. Fifteen patients (18%) were lost to follow-up and were excluded from this analysis leaving a total of 69 patients. Standardized questionnaires were used to analyze clinical outcomes and were administered preoperatively within 3 months of scheduled surgery, and postoperatively at 3, 6, 12, and 24 months. To emphasize the change in clinical outcome scores, the relevant scores were calculated as the ratio of minimal clinically important difference values and change scores. The change scores were calculated by subtracting the postoperative scores from the baseline scores. Multiple regression analyses were conducted to examine the relationship of the duration of symptoms and relevant minimal clinically important difference ratio values while controlling for independent variables. Further, a comparison between 2 groups of patients was performed to analyze the changes of clinical outcomes for the patients who underwent fusion within <24 months versus ≥24 months.

Results:
It was determined that the duration of symptoms was a significant predictor of better leg pain resolution (P=0.018), but not back pain resolution (P=0.27), or improvement in ODI (P=0.10) and SF-36 PCS scores (P=0.19). The patients with shorter duration of symptoms had significantly better radicular symptom resolution (P=0.032) compared with patients who waited at least 24 months or longer to undergo fusion.

Conclusions:
A shorter duration of symptoms was found to be a statistically significant predictor for better resolution of radicular symptoms in patients undergoing TLIF for painful degenerative disk disease and stenosis with spondylolisthesis.
Radiologic and Functional Outcomes in Unstable Thoracolumbar Fractures Treated With Short-segment Pedicle Instrumentation
Authors: Rojas-Tomba Facundo , Hernández-Ruiz Ángel , Menéndez-Quintanilla Ismael , García de Quevedo-Puerta David , Moriel-Durán José , Villanueva-Pareja Francisco 
Published: March 2018

Study Design:
A retrospective review of radiographs, clinical charts, and health questionnaires of 40 patients.

Objective:
To evaluate the radiologic and functional results of unstable thoracolumbar fractures treated with short-segment pedicle instrumentation (SSPI).

A Summary of Background Data:
Although earlier publications report a risk of correction loss or material failure after short-segment fixation in unstable thoracolumbar fractures, more current data suggest that improvements in this technique could offer good clinical and radiologic results.

Materials and Methods:
We undertook a retrospective review of 40 patients with unstable thoracolumbar fractures treated with SSPI. Radiographs and computed tomogrphic scans were analyzed to determine fracture classification and sagittal plane deformity, estimated by the Cobb method. The rates of final kyphosis and correction loss and their relationship with the Load Sharing Classification (LSC) and the AO classification were analyzed. We reviewed the hospital charts to identify complications and outcomes. At the final follow-up, the Short-Form 36 health survey was carried out to evaluate the functional outcome. The relationship between conditions such as polytrauma, neurological compromise or fracture site, and radiological and functional outcomes was also analyzed.

Results:
We observed mean values of 5.9 degrees of final follow-up kyphosis and 5.1 degrees of correction loss. One case of material failure was seen. The severity in the LSC or the AO classification, polytrauma, neurological compromise, or fracture site had no relationship with worse radiologic or functional outcomes.

Conclusions:
SSPI shows good results in fracture reduction, with good functional outcomes despite the loss of correction seen at the final follow-up. Although no investigated variable was found to be predictive of radiographic failure, a trend was identified (P=0.07) that patients with a higher LSC had an increased loss of correction.
Cervical Disk Arthroplasty Versus Anterior Cervical Decompression and Fusion for the Treatment of 2-Level Cervical Spondylopathy
Authors: Kuang Lei , Chen Yuqiao , Wang Bing , Li Lei , Lü Guohua 
Published: March 2018

Study Design:
Systematic review and meta-analysis.

Objective:
To assess the safety and efficacy of cervical disk arthroplasty (CDA) compared with anterior cervical decompression and fusion (ACDF) for the treatment of 2-level cervical spondylopathy.

Summary of Background Data:
CDA has emerged as a potential alternative to ACDF in patients with cervical disk degeneration. But there are no published systematic reviews and meta-analyses comparing CDA with ACDF for the treatment of 2-level cervical spondylopathy.

Methods:
The Pubmed, Embase, Web of science, Scopus, and Cochrane library databases were searched comparing CDA to ACDF in patients with 2-level cervical spondylopathy. Outcome measures were neck disability index, visual analog scale (VAS) of arm and neck pain, range of movement (ROM) at C2–C7, functional segment unit ROM, ROM at the operated level, and incidence of radiologic changes at adjacent levels approximately 2 years after surgery, as well as operating time and incidence of surgery-related complications. Mean difference (MD), odds ratios (OR), and their corresponding 95% confidence intervals (95% CIs) were calculated.

Results:
Six studies involving 646 patients were included. There were no significant differences in neck disability index (MD, −1.53; 95% CI −3.80 to 0.73), VAS neck pain (MD, −0.19; 95% CI −0.71 to 0.33), and VAS arm pain (MD, −0.23; 95% CI −0.61 to 0.16) between 2-level CDA and 2-level ACDF cases. ROM at C2–C7 (MD, 15.82; 95% CI, 10.66–20.99), functional segment unit ROM (MD, 8.58; 95% CI, 7.93–9.23), and ROM at the operated level (MD, 9.54; 95% CI, 7.73–11.35) were greater, but the incidence of radiologic changes at adjacent levels (OR, 0.29; 95% CI, 0.13–0.67) were lower, in 2-level CDA cases. In 2-level CDA cases, the operating time was longer (MD, 57.41; 95% CI, 24.67–90.14), but surgery-related complications rates (OR, 0.47; 95% CI, 0.30–0.74) was lower.

Conclusions:
CDA may be a safe and effective alternative to ACDF for the treatment of 2-level cervical degenerative disease.

Level of Evidence:
Level II.
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.