The pB-C2 Serves as an Optimal Evaluation Parameter For The Surgical Management of Patients With Type A Basilar Invagination.

Objective: To assess the clinical impact of direct two-step distraction reduction (TSDR) for basilar invagination (BI) with atlantoaxial dislocation (AAD). Methods: Retrospective analysis was conducted on the clinical data of patients who underwent TSDR and occipitocervical fusion in West China Hospital between October 2013 and March 2021. Depending on whether the preoperative decrease was greater than 50% on preoperative hyperextension X-rays, the patients were split into two groups. The neurological function [Japanese Orthopedic Association (JOA) score], atlantodens interval (ADI), the distance of odontoid process beyond McRae Line (ML) and Wackenheim Line (WL), cervicomedullary angle (CMA), O-C2 angle (OC2A), and complications incidence were compared between two groups preoperatively and postoperatively. Results: There were 12 men and 23 women among the 35 patients with BI and AAD, and the age ranged from 28 to 71 years, with an mean age of (52.0±13.4) years. In the preoperative reduction ≥50% group, there were 4 males and 9 females with an average age of (54.0±13.8) years; in the preoperative reduction <50% group, there were 8 males and 14 females with a mean age of (50.9±13.4) years. All the patients were followed-up for a mean time of (23.3±13.4) months. There was no significant difference in age, gender, bleeding, length of hospital stay and follow-up time between the two groups (all P>0.05). The JOA score, ADI, WL, ML and CMA of 35 patients were significantly improved when compared with those before operation (all P<0.05). The reduction degree of ADI, ML and WL was more than 80% in 31 cases (88.57%), 30 cases (85.71%) and 31 cases (88.57%), respectively. There was no significant difference in postoperative ADI, ML and WL between the two groups (all P>0.05). All patients had no incision infection, no loosening or breakage of the internal fixators. Dysphagia occurred in 3 patients, non-fusion happened in 1 patient, but no instability in X-ray of cervical dynamic position was found, no loosening or displacement occurred in internal fixators, and partial spontaneous fusion occurred between atlantoaxial lateral mass joints. Conclusions: For BI with AAD without atlantoaxial bony connection or serious atlantoaxial facet joint inclination, TSDR could obtain satisfactory reduction degree. The reduction degree on preoperative hyperextension X-ray doesn't affect the degree of intraoperative reduction.

BackgroundThe revision surgery of basilar invagination (BI) with irreducible atlantoaxial dislocation (IAAD) after a previous occipitocervical fusion (OCF) is challenging. Transoral revision surgery has more advantages than a combined anterior and posterior approach in addressing this pathology. The C-JAWS is a cervical compressive staple that has been used in the lower cervical spine with many advantages. Up to now, there is no report on the application of C-JAWS in the atlantoaxial joint. We therefore present this report to investigate the clinical outcomes of transoral intraarticular cage distraction and C-JAWS fixation for revision of BI with IAAD.MethodsFrom June 2011 to June 2015, 9 patients with BI and IAAD were revised by this technique after previous posterior OCF in our department. Plain cervical radiographs, computed tomographic scans and magnetic resonance imaging were obtained pre- and postoperatively to assess the degree of atlantoaxial dislocation and compression of the cervical cord. The Japanese Orthopedic Association (JOA) score was used to evaluate the neurological function.ResultsThe revision surgeries were successfully performed in all patients. The average follow-up duration was 18.9 ± 7.3 months (range 9–30 months). The postoperative atlas-dens interval (ADI), cervicomedullary angle (CMA), distance between the top of the odontoid process and the Chamberlain line (CL) and JOA score were significantly improved in all patients (P < 0.05). Bony fusion was achieved after 3–9 months in all cases. No patients developed recurrent atlantoaxial instability.ConclusionsTransoral revision surgery by intraarticular cage distraction and C-JAWS fixation could provide a satisfactory outcome for BI with IAAD after a previous unsuccessful posterior operation.

To investigate the effect of modified lateral mass screws implantation strategy on axial symptoms in cervical expansive open-door laminoplasty. A clinical data of 166 patients, who underwent cervical expansive open-door laminoplasty between August 2011 and July 2016 and met the selection criteria, was retrospective analyzed. Among them, 81 patients were admitted before August 2014 using the traditional mini-plate placement and lateral mass screws implantation strategy (control group), and 85 patients were admitted after August 2014 using modified lateral mass screws implantation strategy (modified group). There was no significant difference in the gender composition, age, clinical diagnosis, disease duration, diseased segment, and preoperative Japanese Orthopaedic Association (JOA) score, pain visual analogue scale (VAS) score, Neck Disability Index (NDI), cervical curvature and range of motion, spinal canal diameter and cross-sectional areas, and Pavlov's value between the two groups ( P>0.05). The operation time, intraoperative blood loss, the number of facet joints penetrated by lateral mass screws, effectiveness evaluation indexes (JOA score and improvement rate, VAS score, NDI), imaging evaluation indexes (cervical curvature and range of motion, spinal canal diameter and cross-sectional areas, Pavlov's value, and lamina open angle), and complications were recorded and compared between the two groups. The modified group had shorter operation time and lower intraoperative blood loss than the control group ( P<0.05). There were 121 (29.9%, 121/405) and 10 (2.4%, 10/417) facet joints penetrated by lateral mass screws in control and modified groups, respectively; and the difference in incidence was significant ( χ 2=115.797, P=0.000). Eighteen patients in control group had 3 or more facet joints penetrated while no patients in modified group suffered 3 or more facet joint penetrated. The difference between the two groups was significant ( P=0.000). All patients were followed up, the follow-up time was (28.7±4.9) months in modified group and (42.4±10.7) months in control group, showing significant difference ( t=10.718, P=0.000). The JOA score, VAS score, and NDI at last follow-up of the two groups were significantly improved compared with preoperative ( P<0.05); there was no significant difference in JOA score and improvement rate and VAS score between the two groups ( P>0.05), but the NDI was significantly lower in modified group than in control group ( P<0.05). There were significant differences in cervical curvature and range of motion, spinal canal diameter, Pavlov's value, and cross-sectional areas at last follow-up when compared with those before operation in both groups ( P<0.05). There was no significant difference in the above indicators and lamina open angle between the two groups ( P>0.05). The modified group has a relative lower axial symptom rate (23/85, 27.1%) than the control group (27/81, 33.3%), but the difference was not significant ( Z=-1.446, P=0.148). There was no significant differences between the two groups in the incidences of C 5 nerve root palsy, cerebrospinal fluid leakage, wound infection, and lung or urinary tract infection ( P>0.05). In the cervical expansive open-door laminoplasty, the modified lateral mass screws implantation strategy can effectively reduce the risk of lateral mass screw penetrated to the cervical facet joints, and thus has a positive significance in avoiding the axial symptoms caused by facet joint destruction.

The surgical management of basilar invagination without atlantoaxial dislocation (type B basilar invagination) remains controversial. Hence, we have reported the use of posterior intra-articular C1-2 facet distraction, fixation, and cantilever technique versus foramen magnum decompression in treating type B basilar invagination as well as the results and surgical indications for this procedure. This was a single-center retrospective cohort study. Fifty-four patients who underwent intra-articular distraction, fixation, and cantilever reduction (experimental group) and foramen magnum decompression (control group) were enrolled in this study. Distance from odontoid tip to Chamberlain's line, clivus-canal angle, cervicomedullary angle, craniovertebral junction (CVJ) triangle area, width of subarachnoid space and syrinx were used for radiographic assessment. Japanese Orthopedic Association (JOA) scores and 12-item Short Form health survey (SF-12) scores were used for clinical assessment. All patients in the experimental group had a better reduction of basilar invagination and better relief of pressure on nerves. JOA scores and SF-12 scores also had better improvements in the experimental group postoperation. SF-12 score improvement was associated with preoperative CVJ triangle area (Pearson index, 0.515; p = 0.004), cutoff value of 2.00 cm2 indicating the surgical indication of our technique. No severe complications or infections occurred. Posterior intra-articular C1-2 facet distraction, fixation, and cantilever reduction technique is an effective treatment for type B basilar invagination. As various factors involved, other treatment strategies should also be investigated.

To investigate the effect of ultrasonic bone curette in anterior cervical spine surgery. A clinical data of 63 patients with cervical spondylosis who were admitted between September 2019 and June 2021 and met the selection criteria was retrospectively analyzed. Among them, 32 cases were operated with conventional instruments (group A) and 31 cases with ultrasonic bone curette (group B). There was no significant difference between the two groups (P>0.05) in gender, age, surgical procedure, surgical segment and number of occupied cervical space, disease type and duration, comorbidities, and preoperative Japanese Orthopaedic Association (JOA) score, cervical dysfunction index (NDI), and pain visual analogue scale (VAS) score. The operation time, intraoperative bleeding, postoperative drainage, postoperative hospital stay, and the occurrence of postoperative complications were recorded in both groups. Before operation and at 1, 3, and 6 months after operation, the JOA score and NDI were used to evaluate the function and the postoperative JOA improvement rate was calculated, and VAS score was used to evaluate the pain improvement. The anteroposterior and lateral cervical X-ray films were taken at 1, 3, and 6 months after operation to observe whether there was any significant loosening and displacement of internal fixators. Compared with group A, group B had shorter operation time and postoperative hospital stay, less intraoperative bleeding and postoperative drainage, and the differences were significant (P<0.05). All incisions healed by first intention in the two groups, and postoperative complications occurred in 5 cases (15.6%) in group A and 2 cases (6.5%) in group B, showing no significant difference (P>0.05). All patients were followed up 6-12 months (mean, 7.9 months). The JOA score and improvement rate gradually increased in groups A and B after operation, while the VAS score and NDI gradually decreased. There was no significant difference in VAS score between 3 months and 1 month in group B (P>0.05), and there were significant differences between the other time points of each indicator in the two groups (P<0.05). At 1, 3, and 6 months after operation, the JOA score and improvement rate in group B were better than those in group A (P<0.05). X-ray films examination showed that there was no screw loosening or titanium plate displacement in the two groups after operation, and the intervertebral cage or titanium mesh significantly sank. Compared with traditional instruments, the use of ultrasonic bone curette assisted osteotomy in anterior cervical spine surgery has the advantages of shorter operation time, less intraoperative bleeding, less postoperative drainage, and shorter hospital stay.

Objective To investigate and analyze the postoperative progression of ossification of the patients with ossification of the posterior longitudinal ligament (OPLL) on cervical spine. Methods From Jaunary 2001 to December 2007, 95 postoperative patients with cervical OPLL were followed and analyzed retrospectively. There are 72 males, 23 females, with the average age of 56.3 years (range, 40-73years). The follow-up time was from 1 to 6 years, average 3.1 years. Among them 36 patients were performed with anterior cervical corpectomy, fusion with titanium mesh and fixed with cervical plates, others treated with posterior cervical laminectomy and fixation. 2 of the 95 cases were performed anterior and posterior combined operation. Clinical data, X-rays, CT and MR images and progression of ossification, were measured and analyzed in details .The relationships between the progression of ossification and relative factors, as gender, age, C3 ossified involved, T-OPLL, OPLL-type, time of follow-up, surgical approach, Japanese Orthopaedic Association (JOA) scores and improvement rate of JOA scores, were analyzed. Results Progression of ossification in 39 cases among the 95 followed postoperative OPLL patients, 28 men and 11 women, average age 55.9 years, range 41-71 years. The age of progressed patients included 12 cases of ≤49 years, 12of 50-59 years, 12 of 60-69 years and 3 of ≥70 years. 35 patients were operated by posterior approach and only 4 treated with anterior operation. According to the standard of the progression of ossification that 2 mm in the length or/and thickness, there are 4 cases progressed only in length, 2 only in thickness, other 33 patients both the length and thickness. Progression of length is from 2mm to 20mm (average 7.74±4.71). But thickness is progressed from 2 mm to 6 mm (average 2.67±1.51). From 1 to 3 years follow-up time it appeard as a downtrend about the progression of ossification. But it may appear an uptrend from the 4th year. JOA score and improvement rate of the JOA score were almost improved to the high-point in three years. And according to the statistic data there are obvious relationship between progression of ossification with age, surgical approach and C3 ossified involved. Conclusion There is a high rate of postoperative ossification progression in cervical OPLL patients. Cervical OPLL patients with C3 ossification involved, performed with posterior laminectomy and those young at surgery may have higher rate of progression of the ossification. The JOA score and improvement rate of the JOA score were little influenced by the progression of the OPLL during the short and intermediate-term follow-up. Key words: Cervical vertebrae; Ossification of posterior longitudinal ligament; Treatment outcome

Purpose We evaluate the efficacy, safety and indications of single stage posterior release, reduction, and fixation of basilar invagination (BI) with irreducible atlantoaxial dislocation (IAAD). Materials and methods Seventeen patients with BI and IAAD consecutively underwent one-stage release, reduction, and fixation by a posterior approach from July 2000 to June 2015 were followed up for at least 12 months. There were 8 males. Mean age was 56 35.2 ± 13.8 years (range 12–56). The clinical symptoms and signs of the patients were recorded. Pre- and postoperative imaging examinations were performed. Neurological function was assessed using the Japanese Orthopedic Association (JOA) and Ranawat scores. Results Average follow-up time was 47.4 months (12–97 months). The JOA score increased from preoperative 4–10 (8.06 ± 2.52) to postoperative 13–16 (15.20 ± 0.62). The preoperative Chamberlain line, McRae line, Wackenheim line, atlantodens interval, and cervico medullary angle were 12.52 ± 5.17 mm, 6.59 ± 3.04 mm, 6.96 ± 4.32 mm, 9.88 ± 1.93 mm, and 115.35 ± 12.40°, respectively. The postoperative values were 2.0 ± 3.67 mm, −3.06 ± 1.85 mm, −1.76 ± 2.88 mm, 1.17 ± 1.18 mm, and 136.76 ± 11.44°, respectively. Conclusion One-stage release, reduction, and fixation for patients with BI and IAAD through a posterior approach is safe and efficient.

To investigate the safety and reliability of ultrasonic bone curette in posterior cervical single open-door laminoplasty. The clinical data were retrospectively analyzed, from 193 patients who underwent single open-door laminoplasty (C 3-7) from January 2012 to January 2016. The patients were divided into three groups according to different instruments: posterior single open-door laminoplasty was performed with ultrasonic bone curette in 61 cases (group A), with bite forceps in 73 cases (group B), and with micro-grinding drill in 59 cases (group C). There was no significant difference in gender, age, the course of disease, underlying disease and preoperative Japanese Orthopedic Association (JOA) score, visual analogue scale (VAS) between groups ( P>0.05). The operative time, intraoperative blood loss, drainage volume at 48 hours, JOA score, improvement rate, VAS and perioperative com-plication were compared. The operative time, intraoperative blood loss, and drainage volume at 48 hours of group A were significantly less than those in groups B and C ( P<0.05), but there was no significant between groups B and C ( P>0.05). The follow-up time was 12-21 months (mean, 14.6 months) in group A, 24-36 months (mean, 27.5 months) in group B, and 28-47 months (mean, 38.1 months) in group C. There were no cerebrospinal fluid leakage and incision infection in three groups. No complications of internal fixation loosening and rupture occurred during the follow-up. Rediating pain occurred in 6 cases of group A, 8 cases of group B, and 6 cases of group C, and was cured at 1 week after dehydration and physical therapy. No nerve root palsy was found in three groups. Fracture of portal axis occurred in 5 cases (7 segments) of group B and was fixed by micro titanium plate. The JOA score and VAS score at last follow-up were significantly improved when compared with preoperative scores in three groups ( P<0.05); there was no significant difference in JOA score and improvement rate and VAS score between groups ( P>0.05). It is safe and reliable to use the ultrasonic bone curette in posterior cervical single open-door laminoplasty. It can shorten the operative time and has similar clinical curative effect to the traditional operation, and the lateral rotation of the lamina can be avoided.

Effects of transverse connector on reduction and fixation of atlantoaxial dislocation and basilar invagination using posterior C1–C2 screw-rod technique

Prognostic value of changes in spinal cord signal intensity on magnetic resonance imaging in patients with cervical compressive myelopathy

A retrospective study. To develop a new MRI scoring system to assess patients' clinical characteristics, outcomes and complications. A retrospective 1-year follow-up study of 366 patients with cervical spondylosis from 2017 to 2021. The CCCFLS scores (cervical curvature and balance (CC), spinal cord curvature (SC), spinal cord compression ratio (CR), cerebrospinal fluid space (CFS). Spinal cord and lesion location (SL). Increased Signal Intensity (ISI) were divided into Mild group (0-6), Moderate group (6-12), and Severe group (12-18) for comparison, and the Japanese Orthopaedic Association (JOA) scores, visual analog scale (VAS), numerical rating scale (NRS), Neck Disability Index (NDI) and Nurick scores were evaluated. Correlation and regression analyses were performed between each variable and the total model in relation to clinical symptoms and C5 palsy. The CCCFLS scoring system was linearly correlated with JOA, NRS, Nurick and NDI scores, with significant differences in JOA scores among patients with different CC, CR, CFS, ISI scores, with a predictive model (R2 = 69.3%), and significant differences in preoperative and final follow-up clinical scores among the 3 groups, with a higher rate of improvement in JOA in the severe group (P < .05), while patients with and without C5 paralysis had significant differences in preoperative SC and SL (P < .05). CCCFLS scoring system can be divided into mild (0-6). moderate (6-12), severe (12-18) groups. It can effectively reflect the severity of clinical symptoms, and the improvement rate of JOA is better in the severe group, while the preoperative SC and SL scores are closely related to C5 palsy. III.

To investigate whether congenital cervical spinal stenosis (CCSS) affects the outcome of three-level anterior cervical discectomy and fusion (ACDF) in patients with cervical spondylotic myelopathy (CSM). One hundred seventeen patients with CSM who underwent three-level ACDF between January 2019 and January 2023 were retrospectively examined. Patients were grouped according to presence of CCSS, which was defined as Pavlov ratio ≤ 0.75. The CCSS and no CCSS groups comprised 68 (58.1%) and 49 (41.9%) patients, respectively. The Japanese Orthopaedic Association (JOA) score did not significantly differ between the two groups at any postoperative time point (p > 0.05). The JOA improvement rate was lower in the CCSS group 1 month after surgery (41.7% vs. 45.5%, p < 0.05), but showed no difference at any follow-up time point after one month. Multivariate logistic regression identified preoperative age (OR = 10.639), JOA score (OR = 0.370), increased signal intensity (ISI) in the spinal cord on T2-weighted MRI (T2-WI) (Grade 1: OR = 6.135; Grade 2: OR = 29.892), and degree of spinal cord compression (30-60%: OR = 17.919; ≥60%: OR = 46.624) as independent predictors of a poor oneyear outcome (JOA recovery rate < 50%). Although early JOA improvement is slower in the CCSS group, it does not affect the final neurological improvement at 1 year. Therefore, CCSS should not be considered a contraindication for three-level ACDF in patients with CSM. The main factors influencing oneyear outcome were preoperative age, JOA score, ISI grade, and degree of spinal cord compression.

The correlation among syrinx resolution, occipitoaxial sagittal alignment, and surgical outcome in long-term follow-up seems to have not been clarified. To further explore the relationship between the syrinx resolution and occipitoaxial realignment after posterior reduction and fixation in basilar invagination (BI)-atlantoaxial dislocation (AAD) patients with syringomyelia. A continuous series of 32 patients with BI-AAD and syringomyelia who received direct posterior reduction met the inclusion criteria of this study. Their clinical and imaging data were analyzed retrospectively. Before surgery and at the last follow-up, we used the Japanese Orthopedic Association (JOA) score and the Neck Disability Index (NDI) to assess the neurological status, respectively. The Pearson correlation coefficient and multiple stepwise regression analysis were used to explore the relevant factors that may affect surgical outcomes. There were significant differences in atlantodental interval, clivus-axial angle, occiput-C2 angle (Oc-C2A), cervicomedullary angle (CMA), subarachnoid space (SAS) at the foramen magnum (FM), syrinx size, NDI, and JOA score after surgery compared with those before surgery. ΔCMA and the resolution rate of syrinx/cord as relevant factors were correlated with the recovery rate of JOA (R 2 = 0.578, P < .001) and NDI (R 2 = 0.369, P < .01). What's more, ΔSAS/FMD (SAS/FM diameter) and ΔOc-C2A were positively correlated with the resolution rate of syrinx/cord (R 2 = 0.643, P < .001). With medulla decompression and occipital-cervical sagittal realignment after posterior reduction and fusion for BI-AAD patients with syringomyelia, the structural remodeling of the craniovertebral junction and occipitoaxial realignment could contribute to syringomyelia resolution.

BackgroundThe optimal surgical techniques for cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial due to insufficient high-level evidence. We investigated the following surgical approaches for cervical OPLL: anterior decompression and fusion (ADF), anterior cervical corpectomy and fusion (ACCF), anterior controllable antedisplacement fusion (ACAF), anterior cervical discectomy and fusion (ACDF), posterior decompression with instrumented fusion (PDIF), posterior decompression and fusion (PDF), laminectomy (LC), laminoplasty (LP), laminectomy with fusion (LF), and vertebral body sliding osteotomy (VBSO).MethodsWe systematically searched PubMed, Embase, Ovid, the Cochrane Library, and Web of Science from database inception through October 30, 2024. Our search identified both randomized and non-randomized controlled trials compar ing the following surgical interventions: ACDF, ADF, ACCF, ACAF, PDIF, PDF, LC, LP, LF, and VBSO. The extracted data were subjected to network meta-analysis. Our analysis included the following outcome measures: Patient demographic characteristics, Japanese Orthopaedic Association (JOA) scores, JOA improvement rates, overall complication rates, excellent/good recovery rates, cervical lordosis characteristics, Visual Analog Scale (VAS) scores, Neck Disability Index (NDI) scores, surgical duration and intraoperative blood loss.ResultsIn our analysis of 50 studies involving 8705 patients, ACAF demonstrated the most significant improvements in JOA scores, cervical lordosis, VAS scores, and NDI scores. ADF showed the greatest increase in JOA improvement rate, while VBSO had the highest rate of excellent and good postoperative recovery. ACDF was associated with the fewest total complications and the shortest surgical duration. Finally, LC resulted in the lowest intraoperative blood loss.ConclusionThis studies demonstrate that ACAF significantly improves JOA scores and cervical lordosis while reducing VAS and NDI scores. Additionally, it achieves higher postoperative JOA improvement rates and excellent/good recovery rates, with fewer total complications and reduced intraoperative blood loss. Based on these findings, ACAF can be one of the preferred options for clinicians treating cervical OPLL, but it requires high surgical experience and strict indication selection. Additionally, the surgical team need to develop the best surgical plan based on imaging features and patient functional needs.

Objective To analyze efficacy of double door laminoplasty for treatment of whiplash injury of the cervical spine.Methods Forty-one cases of cervical whiplash injury treated surgically from January 2001 to October 2011 and available to follow up were analyzed retrospectively.There were 32 males and 9 females with mean age of (51.0 ± 12.0) years (range,28 to 74 years).Causes of injury included traffic accidents in 30 cases,fall on the ground in 8,and high fall in 3.All cases were combined with developmental cervical stenosis and six with ossification of the posterior longitudinal ligament.Posterior double-door laminoplasty was operated in 36 cases and one-stage surgery via anterior-posterior approach in 5 cases.Cases were grouped according to their ages,preoperative cervical Japanese Orthopedic Association (JOA) score,and operation time.Results were compared among groups.Results Operation lasted for 70-180 minutes (mean,121.9 minutes) and showed blood loss of 30-500 ml (mean,177.8 ml).All cases were followed up for 12 to 110 months (mean,59.4 months).Overall JOA score averaging 14.7 points improved significantly after operation with mean improvement rate of 77.8％ (P ＜0.01).Whereas between non-elderly and elderly groups,postoperative JOA improvement rate [(79.6 ± 18.8)％ vs (73.5 ±22.8)％] and excellent rate (90％ vs 83％) were similar.For cases grouped according to their preoperative JOA score,the results were satisfactory for all groups,but the differences were insignificant.Besides,JOA score at the last follow-up differed significantly among groups (P ＜ 0.0l).Improvement rate of JOA score was better in early surgery group than in late surgery group [(84.6±13.3)％ vs (75.4±24.0)％,P＜0.05].Conclusions Double door laminoplasty is reliable in treatment of cervical whiplash injury on condition that surgical indications are grasped strictly.Elderly or gravely injured patients can also have considerable recovery of neurological function,but patients with severe injury or late surgery are associated with poor prognosis. Key words: Spinal cord injuries; Cervical vertebrae; Whiplash injury