Average Neck Disability Index Research Articles

Association between neck and shoulder pain and smartphone usage among students of Da Nang University of Medical Technology and Pharmacy

Smartphone addiction can lead to physical and psychological disorders in users, such as headache, lack of concentration, insomnia, fatigue, increased neck pain and disabilities with reduced range of neck flexion and extension. The main aim of this study was to investigate the association between non - specific neck and shoulder pain and the use of smartphones. A cross - sectional study among 416 undergraduate students from Danang University of Medical Technology and Pharmacy was conducted in 2019. The smartphone addiction scale - short version (SAS-SV) was used to assess smartphone addiction among students while the Neck Disability Index (NDI) scale was used to measure the severity of shoulder pain. Multivariate logistic regression models were used to seek associations between smartphone usage and students’ neck and shoulder pain. The prevalence of smartphone addiction among participants was 46.6%. The average NDI score was 5.31 ± 3.81. The results showed that daily average time using smartphones (p = 0.018) and the posture when using smartphones (p = 0.03) were significantly correlated to the severity of neck and shoulder pain. The multivariate logistic regression models indicated that the factors that have an independent impact on the student’s shoulder and neck pain were gender, school year and the addiction to smartphones. It is recommended to reduce the duration of smartphone use and maintain the proper body posture while using it such as sitting on a chair with a backrest, avoiding unfavorable positions such as lying or standing.

Association of ≥ 12 months of delayed surgical treatment for cervical myelopathy with worsened postoperative outcomes: a multicenter analysis of the Quality Outcomes Database.

Degenerative cervical myelopathy (DCM) results in significant morbidity. The duration of symptoms prior to surgical intervention may be associated with postoperative surgical outcomes and functional recovery. The authors' objective was to investigate whether delayed surgical treatment for DCM is associated with worsened postoperative outcomes. Data from 1036 patients across 14 surgical centers in the Quality Outcomes Database were analyzed. Baseline demographic characteristics and findings of preoperative and postoperative symptom evaluations, including duration of symptoms, were assessed. Postoperative functional outcomes were measured using the Neck Disability Index (NDI) and modified Japanese Orthopaedic Association (mJOA) scale. Symptom duration was classified as either less than 12 months or 12 months or greater. Univariable and multivariable regression were used to evaluate for the associations between symptom duration and postoperative outcomes. In this study, 513 patients (49.5%) presented with symptom duration < 12 months, and 523 (50.5%) had symptoms for 12 months or longer. Patients with longer symptom duration had higher BMI and higher prevalence of anxiety and diabetes (all p < 0.05). Symptom duration ≥ 12 months was associated with higher average baseline NDI score (41 vs 36, p < 0.01). However, improvements in NDI scores from baseline were not significantly different between groups at 3 months (p = 0.77) or 12 months (p = 0.51). Likewise, the authors found no significant differences between groups in changes in mJOA scores from baseline to 3 months or 12 months (both p > 0.05). Surgical intervention resulted in improved mJOA and NDI scores at 3 months, and this improvement was sustained in both patients with short and longer initial symptom duration. Patients with DCM can still undergo successful surgical management despite delayed presentation.

Anterior Cervical Discectomy and Fusion Combined with Foraminotomy Assisted by High-Definition 3-Dimensional Exoscope in the Treatment of Cervical Spondylotic Radiculopathy Secondary to Bony Foraminal Stenosis.

ObjectiveTo evaluate the outcomes of cervical spondylotic radiculopathy secondary to bony foraminal stenosis treated with anterior cervical discectomy and fusion (ACDF) combined with anterior cervical foraminotomy (ACF) assisted by High‐Definition 3‐Dimensional Exoscope.MethodsIn this retrospective study, a total of 19 consecutive patients (12 males and seven females, with an average of 49.2 years, range from 40 to 59 years) with spondylotic radiculopathy caused by bony foraminal stenosis underwent ACDF combined with ACF assisted by High‐Definition 3‐Dimensional Exoscope in our hospital between January 2019 and December 2019 were included in this study. All patients signed the consent form before the surgery. The patient baseline information such as gender, age, body mass index (BMI), surgery time, blood loss, hospital stay, lesion segment, side, follow‐up time and postoperative complications were recorded. The Japanese Orthopedic Association (JOA), Neck Disability Index (NDI), and Visual Analogue Scale (VAS) were measured and compared before surgery, 1 months and final follow‐up after surgery. The radiographic outcomes were evaluated using the C2‐C7 angel, disc height, foraminal height, superior diagonal distance, inferior diagonal distance, and foraminal area.ResultsThe involved levels included C4‐C5 (six cases), C5‐C6 (10 cases), C6‐C7 (three cases). The mean duration of the surgery, mean blood loss, mean hospital stay, and mean follow‐up were 100 ± 11.10 min, 19.4 ± 7.05 mL, 7.1 ± 0.99 days, and 12.1 ± 2.25 months, respectively. The average preoperative JOA score was 11.9 ± 1.31, then improved to 15.7 ± 0.73 (t = −13.45, P < 0.001) and 16.2 ± 0.74 (t = −14.39, P < 0.001) at 1 month after operation and at last follow‐up, respectively. The average preoperative NDI score was 27.3 ± 3.36, then decreased to 5.1 ± 1.79 (t = 20.63, P < 0.001) and 4.5 ± 1.21 (t = 25.53, P < 0.001) 1 month after operation and at last follow‐up, respectively. The average preoperative VAS score was 6.7 ± 0.93, then decreased to 2.4 ± 0.69 (t = 15.05, P < 0.001) and 1.9 ± 0.78 (t = 16.40, P < 0.001) 1 month after operation and at last follow‐up, respectively. As compared with the condition before surgery, there was a significant improvement in the C2‐C7 angel, disc height, foraminal height, and foraminal area (P < 0.05). None of the patients developed postoperative vascular injury, nerve injury, loosening and rupture of the internal fixation, displacement of interbody fusion cage, and pseudarthrosis.ConclusionACDF combined with ACF assisted by High‐Definition 3‐Dimensional Exoscope is effective and safe for the treatment of CSR caused by secondary to bony foraminal stenosis.

266. Higher paraspinal muscle density effect on outcomes after ACDF

<h3>BACKGROUND CONTEXT</h3> Studies in the lumbar spine suggest a correlation between sarcopenia and worse patient outcomes. To our knowledge, no studies have investigated whether an association exists between fatty degeneration of the cervical paraspinal musculature and cervical disability in the perioperative period. <h3>PURPOSE</h3> The purpose of this study is to determine whether paraspinal Goutalier grade of fat degeneration is associated with patient-reported outcomes in patients undergoing ACDF. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of a prospectively collected cohort of patients who underwent 1 to 3 level ACDF between the years 2011-2014 at a single academic medical center. <h3>PATIENT SAMPLE</h3> Sixty-nine patients who underwent 1-3 level ACDF between the years of 2011-2014. <h3>OUTCOME MEASURES</h3> Goutalier classification, patient-reported outcomes such as neck disability index (NDI), RAND score, and EQ-5D score were measured. <h3>METHODS</h3> We performed a retrospective review of a prospective cohort of patients undergoing 1 to 3 level ACDF at a single institution between the years 2011-2014. We utilized preoperative MRI's to classify patients into Goutalier grades. Patient-reported outcomes including NDI, RAND score and EQ-5D score were collected and analyzed according to patients' Goutalier grade. We utilized Student's t-test and ANOVA to compare all means between groups. The mid-P exact test was used to compare proportional differences between groups. <h3>RESULTS</h3> We identified 69 patients for inclusion. The cohort was 47.3% male. 29 patients were classified as Goutalier 0-1 (Group 1), 29 were Goutalier 1.5-2 (Group 2), and 11 were Goutalier 2.5-4.0 (Group 3). Determination of Goutalier grade by the two reviewers resulted in 82.8% agreement with correlation coefficient of 0.69 (Pearson, r2), demonstrating moderate interrater reliability. All Goutalier groups experienced significant improvement in all three outcome scores. Average postoperative NDI scores were 25.3 in Group 1, 13.9 in Group 2, and 25.1 in Group 3 (p=0.02). The percentage of patients in each group reporting worse disability after surgery was 17.2%, 3.3% and 9.1%, respectively (p=0.05) No statistically significant difference was seen between groups in postoperative EQ-5D (p=0.07) or RAND scores (p>0.05). <h3>CONCLUSIONS</h3> The present study is the first to assess the association between cervical paraspinal muscle Goutalier grade and patient reported outcomes following ACDF. Based upon our study, patients with worse cervical paraspinal degeneration may benefit from improved symptom relief in comparison to patients with a lesser degree of degeneration undergoing ACDF. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

3D-Printed Screw-Rod Auxiliary System for Unstable Atlas Fractures: A Retrospective Analysis.

ObjectiveTo develop and validate the efficacy of a 3D‐printed screw‐rod auxiliary system for unstable atlas fractures.MethodsThis research is a retrospective analysis, and a total of 14 patients, including 11 males and three females, were enrolled in our hospital from January 2017 to March 2019 who underwent occipitocervical fusion assisted by the 3D‐printed screw‐rod auxiliary system were reviewed, and with an average age of 53.21 ± 14.81 years, an average body mass index (BMI) of 23.61 ± 1.93 kg/m2. The operation time, blood loss and radiation times during the operation were recorded. The maximum fracture displacement values of pre‐ and post‐operation were measured based on CT imaging. All screw grades were evaluated after surgery. The occipital‐cervical 2 (O‐C2) angle and occipitocervical inclination (OCI) angle of pre‐operation, post‐operation and the last following‐up were measured. The dysphagia scale 3 months after surgery and at the last follow‐up, the Neck Disability Index (NDI) 3 months after surgery and at the last follow‐up were assessed.ResultsAll patients were completed the surgery successfully. There was no patient with severe dysphagia or aggravation of nerve injury. The follow‐up was from 12 to 14 months, and with an average of 12.5 months. The average surgery time, average blood loss and average radiation times for the 14 patients were 112.14 min, 171.43 mL and 5.07 times, respectively. There was a significant difference in maximum fracture displacement between pre‐ and post‐operation values (P < 0.05). A total of 56 screws were inserted in 14 patients, among them, three screws were classified as grade 1, and the other screws were classified as grade 0. There was a significant difference in the O‐C2 between pre‐operation and 3 days after operation (P = 0.002); There was a significant difference in OCI angles between pre‐operation and 3 days after operation (P < 0.05); there was no significant difference in the O‐C2 or OCI angle between 3 days after the operation and the last follow‐up (P = 0.079; P = 0.201). The dysphagia scales of two patients were assessed as mild at 3 months after surgery, and the others were assessed as normal at 3 months after surgery. All patients' dysphagia scores returned to normal at the last follow‐up. The average NDI and average neck Visual Analogue Scale (VAS) scores at the last follow‐up were 2.53 and 8.41, respectively.ConclusionIt can objectively restore the OCI to normal with few post‐operative complications under the assistance of a screw‐rod auxiliary system to perform occipitocervical fusion for unstable atlas fractures and atlantooccipital joint instability.

Anterior Cervical Surgery for the Treatment of Cervicogenic Headache Caused by Cervical Spondylosis.

Study DesignRetrospective study.ObjectiveTo report the efficacy of anterior cervical surgery for the relief of cervicogenic headache (CEH) caused by cervical spondylosis.MethodsFrom January 2014 to December 2016, a total of 166 cases of cervical radiculopathy and/or myelopathy received anterior cervical decompression and fusion (ACDF) in our institution, among which 50 cases (mean age 44.7 years) were accompanied by CEH and followed up at 3, 6, 12, and 24 months postoperatively, respectively. Neck pain and headache scores according to neck disability index (NDI) were documented for all patients at regular intervals. The results measured at different follow-up time point were compared statistically.ResultsAll 50 patients reported neck pain and headache at the same time before surgery. The average NDIs for neck pain before and after surgery were 2.86 (95% CI: 2.7–3.0) preoperatively, 0.98 (95% CI: 0.8–1.1) at 3 months, 0.68 (95% CI: 0.5–0.9) at 6 months, 0.62 (95% CI: 0.5–0.8) at 12 months, and 0.60 (95% CI: 0.4–0.8) at 24 months postoperatively, respectively. The average NDIs for CEH before and after surgery were 2.32 (95% CI: 2.2–2.5) preoperatively, 0.62 (95% CI: 0.5–0.8) at 3 months, 0.60 (95% CI: 0.4–0.8) at 6 months, 0.56 (95% CI: 0.4–0.7) at 12 months, and 0.50 (95% CI: 0.3–0.7) at 24 months postoperatively, respectively. The neck pain and headache improved in all cases and the NDI score of neck pain or headache at each follow-up point after surgery was significantly different from that before surgery (P <0.001). The simple correlation analysis between neck pain and headache was performed, and the Pearson coefficient r was 0.71, indicating a positive correlation between neck pain NDI and headache NDI. No serious surgical complications were found.ConclusionOur study suggests that patients with cervical spondylosis complicated with CEH are always accompanied by neck pain. ACDF can not only relieve neck pain but also improve the accompanying CEH.

When is the circumferential stabilization necessary for subaxial cervical fracture dislocations? The posterior ligament-bone injury classification and severity score: a novel treatment algorithm.

To propose a novel classification and scoring system called the posterior ligament-bone injury classification and severity score (PLICS) that offers a quantitative score to guide the need for posterior stabilization in addition to anterior reconstruction for subaxial cervical fracture dislocations (SCFDs). A total of 456 patients with SCFDs were prospectively included. Patients with PLICS ≥ 7 together with extremely unstable lateral mass fracture (EULMF) were classified as high-risk group, and the other patients were classified as low-risk group. For patients in the low-risk group, anterior-only reconstruction was performed; for patients in the high-risk group, additional posterior lateral mass fixation and fusion was performed after anterior reconstruction. Clinical outcome evaluation included using the visual analogue score (VAS), the Neck Disability Index (NDI), and the American Spinal Injury Association (ASIA) impairment scale. The change in the local sagittal alignment kyphosis Cobb angle was also recorded. A total of 370 patients (81.1%) completed the minimal 12-month follow-ups, including 321 patients of low-risk group and 49 patients of high-risk group. Compared with the average VAS score preoperatively, the score at 12-month follow-up was significantly improved (from 6.1 + 0.3 to 1.1 + 0.2 in the low-risk group, P < 0.001; from 6.4 + 0.2 to 1.4 + 0.2 in the high-risk group, P < 0.001). The average NDI score at the 12-month follow-up was statistically low in the low-risk group (8.8 + 2.5 vs 13.8 + 3.4, P = 0.034). At least more than one grade improvement in the ASIA scale was observed in 80.5% of all patients. The local kyphosis Cobb angle at the injured segment averaged improved in both groups. A PLICS score ≥ 7 together with EULMF can be the threshold for posterior stabilization in addition to anterior reconstruction for the patients with SCFDs.

Higher Paraspinal Muscle Density Effect on Outcomes After Anterior Cervical Discectomy and Fusion.

Study Design:Retrospective cohort study.Objectives:Studies in the lumbar spine suggest a correlation between sarcopenia and worse patient outcomes. The purpose of this study was to determine whether paraspinal Goutalier grade of fat degeneration is associated with patient-reported outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF).Methods:We performed a retrospective review of a prospective cohort of patients undergoing 1- to 3-level ACDF at a single institution between the years 2011-2014. We utilized preoperative magnetic resonance images to classify patients into Goutalier grades. Patient-reported outcomes, including Neck Disability Index (NDI), RAND score, and EQ-5D score were collected and analyzed according to patients’ Goutalier grade.Results:We identified 69 patients for inclusion. A total of 29 patients were classified as Goutalier 0-1 (group 1), 29 were Goutalier 1.5-2 (group 2), and 11 were Goutalier 2.5-4.0 (group 3). All Goutalier groups experienced significant improvement in all 3 outcome scores. Average postoperative NDI scores were 25.3 in group 1, 13.9 in group 2, and 25.1 in group 3 (P = .02). The percentage of patients in each group reporting worse disability after surgery was 17.2%, 3.3%, and 9.1%, respectively (P = .05). No statistically significant difference was seen between groups in postoperative EQ-5D (P = .07) or RAND scores (P > .05).Conclusions:The present study is the first to assess the association between cervical paraspinal muscle Goutalier grade and patient-reported outcomes following ACDF. Based on our study, patients with worse cervical paraspinal degeneration may benefit from improved symptom relief in comparison to patients with a lesser degree of degeneration undergoing ACDF.

Improvements in Neck Pain and Disability Following C1-C2 Posterior Cervical Instrumentation and Fusion for Atlanto-Axial Osteoarthritis

Symptomatic Atlanto-axial (C1-2) osteoarthritis (AAOA) is a common phenomenon in elderly patients; however, there is a paucity of data on the effectiveness of posterior atlanto-axial fusion (PAAF) for this condition. To this end, here we assess changes in patient-reported outcomes and neck-related disability in adult patients undergoing PAAF for symptomatic C1-2 AAOA. In this retrospective study, the clinical records of consecutive patients with symptomatic AAOA who underwent PAAF between 2004 and 2017 were reviewed. Patient demographics, comorbidities, intraoperative and postoperative variables, and complication rates were collected. Neck Disability Index (NDI) scores were recorded at baseline and 6 weeks, 6 months, 1 year, and 2 years postoperatively. Forty-two patients (average age, 72.04 ± 8.56 years; 26.19% males) met the study's inclusion criteria. In this cohort, 19.04% had previous subaxial cervical spine surgery, 35.71% had a history of smoking (all had stopped smoking before surgery), and 11.90% had type II diabetes. At baseline, the majority of patients had a normal neurologic exam. The average preoperative NDI score was 26.88 ± 24.85, which improved to 10.59 ± 14.88 at the 1-year follow-up and 13.20 ± 14.96 at the 2-year follow-up (P=0.004). At baseline, 18% of the patients reported severe disability based on NDI score; this percentage decreased to 2% at 1 year and 0 at 2 years (P= 0.01). Importantly, a high percentage (11.90%) of patients had undergone previous subaxial cervical fusion for their pain due to a mistaken diagnosis for this condition, without symptom relief. In appropriately selected patients, PAAF may decrease neck pain and improve functional disability in patients with AAOA. Future prospective longitudinal studies are needed to corroborate these findings.

A Combinatorial Approach with Cerebellar Tonsil Suspension to Treating Symptomatic Chiari Malformation Type I in Adults: A Retrospective Study

Primary Chiari malformations (CMs) are congenital defects of the skull base and brain. Among the 4 CM types, type I (CM-I) occurs most frequently and may cause somatosensorimotor, autonomic and vision symptoms. Presently, posterior fossa decompression alone (PFD) or with duraplasty (PFDD) and cerebellar tonsil (CbT) shrinkage tactics are standard treatments, albeit inherent issues. There has been no report on devising CbT suspension (CTS) to manage CM-I. 1) To design a CTS protocol that can be used with CbT coagulation (CTC) and PFDD; 2) to evaluate the regimen for feasibility, safety, and efficacy in a retrospective study; and 3) to obtain data for planning prospective studies to validate PFDD+ CTC+ CTS as a novel approach to treating adult CM-I. PFDD + CTC + CTS (n= 17), PFDD + CTC (n= 13), and PFDD (n= 12) were performed for 42 adult patients (age range, 18-55 years; female:male = 27:15) following a balanced study design. Neck Disability Index (NDI), Chicago Chiari Outcome Scale (CCOS), and /magnetic resonance imaging/computed tomography were used to determine postsurgery outcomes for approximately 20 months. Comparing to PFDD + CTC or PFDD, patients receiving PFDD + CTC +CTS operation exhibited significantly improved group average NDI (10.72 ± 3.95%; P= 0.007), CbT elevation distance (7.06 ± 2.42 mm; P < 0.001, Kruskal-Wallis test; 55.7 ± 25.4% higher than the presurgery level; P < 0.001, analysis of variance), and syringomyelia syrinx retraction (P= 0.009, analysis of variance). The PFDD + CTC + CTS regimen appeared to be safe and potentially more efficacious in patients with CM-I evaluated for the period, relative to PFDD+ CTC or PFDD treatment. Future prospective studies were warranted.

46. Establishing maximal medical improvement following anterior cervical discectomy and fusion

BACKGROUND CONTEXT Identifying patient characteristics that predict MMI achievement may improve surgical care and patient satisfaction. PURPOSE The purpose of this study is to identify the time point at which patients undergoing primary, single-level anterior cervical discectomy and fusion (ACDF) can be considered to have reached maximal medical improvement (MMI). STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE 69 patients undergoing ACDF. OUTCOME MEASURES Maximal Medical Improvement, Neck Disability Index. METHODS A surgical database was retrospectively reviewed between 2014-2017 for patients undergoing ACDF for degenerative pathology. Neck Disability Index (NDI) scores were collected preoperatively and at 6-week, 3-month, 6-month, and 12-month follow-up. The minimal clinically important difference (MCID) was calculated using distribution-based methodology at the 1-year interval and validated using a nonparametric receiver operating characteristic (ROC) curve. Area under curve (AUC) analysis was used to validate predictive power. The time period at which patients achieved MCID was determined and plotted using a Kaplan-Meier survivorship curve. MMI was defined as the interval at which 90% of patients achieved MCID. A Cox hazard proportion model was used to determine whether age, body mass index (BMI), and Charlson Comorbidity Index (CCI) were associated with time to achieve MCID. RESULTS A total of 69 patients were included in the analysis. Average NDI scores were 37.9 preoperatively, 30.7 at 6 weeks, 25.1 at 3 months, 21.3 at 6 months, and 22.0 at 12 months postoperatively. The change in NDI reflective of MCID was calculated to be -11.0 (AUC=100%). In total, 51 patients (73.9%) achieved MCID within the study period, with median time to achievement being 3 months. Of these patients, 95.7% achieved MCID by 6 months postoperatively, thus allowing the establishment of MMI at this time point. No association was identified between age (HR: 1.014, p=0.606), BMI (HR: 0.984, p=0.552), or CCI (HR: 0.932, p=0.719), and time to achieve MCID. CONCLUSIONS The majority of patients undergoing ACDF achieved MCID at 3 months follow-up, while over 95% of patients who achieved MCID reached this threshold by 6 months following surgery. As such, future outcome reporting in patients undergoing ACDF should include follow-up to 6 months postoperatively. Providers can also utilize this information to better counsel patients regarding postoperative expectations following ACDF. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

91. Can the proposed posterior ligament-bone injury classification and severity score predict the failure of anterior-only surgery for subaxial cervical facet dislocations?

BACKGROUND CONTEXT The approach selection for subaxial cervical fracture dislocations (SCFD) is controversial. While spinal surgeons increasingly prefer a single anterior approach, the complication of postoperative cervical kyphosis is worrisome. Hence, identification of suitable candidates requiring a second posterior reconstruction is necessary, thus preventing the failure of anterior-only surgery in patients with SCFD. PURPOSE To introduce a novel classification and scoring system called the posterior ligament-bone injury classification and severity (PLICS) score and verify whether this system can be generally utilized for the treatment of the SCFD to predict the failure of anterior-only surgery. STUDY DESIGN/SETTING A retrospective cohort study. PATIENT SAMPLE A total of 394 patients with SCFD who underwent anterior decompression, reduction, and fusion between January 2002 and December 2017 in one center were retrospectivelyenrolled in the study. The inclusion criteria included: 1. the preoperative magnetic resonance imaging (MRI) detected facture dislocation accompanying with an extruded disc, which deformed the dural sac beyond the line between the postero-inferior corner of cranial vertebrae and the postero-superior corner of caudal vertebrae; 2. the clinical level of neural dysfunction corresponds to the segment of reconstruction without the requirement of an extensive posterior decompression; 3. the reduction can be achieved under an attempt at the awake skull traction preoperatively or via anterior approach after the removal of herniated disc intraopertively. The exclusion criteria included: reduction can't be by preoperative skull traction, or by an anterior approach intraoperatively; the patients obtained a posterior reconstruction surgery when the intramedullary edema may extend beyond the segment of dislocation; severe traumatic cervical spondylolisthesis (over grade 3); the patients are accompanying by ankylosing spondylitis. OUTCOME MEASURES Clinical outcomes with respect to neck pain and function were recorded for each patient according to visual analog score (VAS) and the Neck Disability Index (NDI). We paired the equal number of patients between successful and unsuccessful groups to compare the difference in the clinical outcome. The American Spinal Injury Association (ASIA) impairment scale was recorded at each follow-up interval. Additionally, lateral radiography computed tomography (CT) and MRI were also recommended. METHODS Patients were divided into successful and unsuccessful groups according to whether failure of internal fixation was observed during follow-up. PLICS is based on the injury severity of the ligament-bone structure of three elements. Anatomically, the posterior column of cervical spine can be subdivided into three-column structure, including bilateral facet joints and the outside joint capsules, and posterior spinous processes and the attached ligament structures, so-called posterior ligamentous complex, including the supraspinal ligament and interspinous ligament. In this score system, a specific point value (0 - 3) is assigned to a particular variable within each element reflective of the severity of injury and its contribution to stability of posterior column of cervical spine. The preoperative PLICS score of all patients are recorded respectively. RESULTS Among 354 patients, 89.8% fulfilled the follow-up. Fifteen patients (4.2%) experienced hardware failure and progressive cervical kyphosis at the postoperative follow-up. The patients were divided into successful (15 patients) and unsuccessful (339 patients) groups. The average VAS score in the satisfactory group decreased from 6.7+0.8 to 1.3+0.6. The average VAS score in the unsatisfactory group decreased from 4.9+0.8 to 0.3+0.5. The average NDI score at the12-month follow-up was statistically low in the satisfactory group (6.2+2.1 vs 15.5+3.8, P= .028). It is worth noting that, except for only one patient with a PLICS score of 6, the PLICS score for the other 14 patients who experienced postoperative hardware failure was >7. However, the PLICS score for the other 339 patients (except for 2 cases) who obtained satisfactory radiological outcome was CONCLUSIONS When a PLICS score >7 is accompanied by severe lateral mass fracture, the risk of postoperative failure after an anterior-only reconstruction is high and supplemental posterior strengthening can be considered. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Preoperative and Intraoperative Skull Traction Combined with Anterior-Only Cervical Operation in the Treatment of Severe Cervical Kyphosis (>50 Degrees)

To evaluate the clinical and radiographic outcomes of an anterior-only approach for the correction of severe cervical kyphotic deformities. We performed a retrospective study of 33 consecutive patients with severe cervical kyphosis treated with an anterior cervical operation and preoperative and intraoperative skull traction. Cobb angle, kyphosis index (KI), kyphosis level, C2-7 sagittal vertical axis (SVA), and T1 slope were measured. The preoperative and postoperative Japanese Orthopedic Association (JOA) scores, visual analog scale (VAS) score for neck pain, Neck Disability Index (NDI) scores, and cervical alignment were compared. The mean angle of the kyphosis was 83.2 ±20.4°. The mean Cobb angle of the operative region was 71.7 ± 18.5° preoperation, which was reduced to 10.6 ±5.7° postoperation (mean correction, 85.2%). The mean KI was 75.1 ± 18.2 preoperation, which was reduced to 14.4 ±9.1 postoperation (mean correction, 80.8%). The preoperative and postoperative mean C2-7 Cobb angle was 53.8 ± 16.5° and 14.7 ± 7.6°, respectively. The preoperative and postoperative mean C2-7 SVA was 3.9 ± 14.5 mm and 12.8 ± 7.3 mm, respectively. The preoperative and postoperative mean T1 slope was-9.4 ± 15.7° and 7.3 ± 13.1°, respectively. The average postoperative C2-7 Cobb angle, Cobb angle of the operative region, KI, C2-7 SVA, and T1 slope changed significantly compared with preoperative values (P < 0.05). The average postoperative JOA, VAS, and NDI scores improved significantly compared with preoperative scores (P < 0.05). Preoperative and intraoperative skull traction combined with anterior-only cervical operation may be a safe and effective technique for treating severe cervical kyphosis. If the postoperative correction is >80%, sufficient decompression could be achieved.

Functional, Radiological and Sagittal Balance Outcomes in Surgically Treated Degenerative Cervical Disc Diseases

Background: The treatment of degenerative spinal diseases remains focused on dealing with symptoms, using both conservative and surgical methods. Though surgery is considered an effective treatment for many cervical disorders, at times it leads to significant problems including adjacent level disease. Objectives: The aim of this study was to correlate the functional, radiographic and sagittal balance outcome in surgically treated patients for the degenerative cervical disc diseases, outline the advantages, disadvantages and the effect of the sagittal balance on the patient function and activities. Patients and Methods: This study included a total of thirty patients who had degenerative disc disease of the cervical spine at multiple levels treated by microscopic anterior cervical decompression. The average age of participants was 43.267 ± 10.780 years (26– 64). 18 patients (60%) were females and 12 patients (40%) were males. All patients were assessed and classified before and after surgery using the neck disability index and visual analogue scale. This assessment was done for both neck and arm disability. Results: The average neck disability index at the last follow-up was 17.74 ± 2.135, which was statistically significant (P < 0.05) among groups and visual analogue scale improved from 7.4 ± 0.926 to reach 3.6 ± 0.35 six months postoperatively. Full recovery was obtained between three and six months. All patients underwent a rehabilitation protocol and found no postoperative neurological deficit in this series. Conclusions: It could be concluded that cervical sagittal imbalance arising from regional and/or global spinal sagittal malalignment plays an independent role in exacerbating adjacent segment pathomechanics after multilevel fusion and should be considered during cervical fusion surgical planning. Also, it concludes that surgery significantly led to improvement of symptoms three months post operatively.

Functional, Radiological and Sagittal Balance Outcomes in Surgically Treated Degenerative Cervical Disc Diseases

Background: The treatment of degenerative spinal diseases remains focused on dealing with symptoms, using both conservative and surgical methods. Though surgery is considered an effective treatment for many cervical disorders, at times it leads to significant problems including adjacent level disease. Objectives: The aim of this study was to correlate the functional, radiographic and sagittal balance outcome in surgically treated patients for the degenerative cervical disc diseases, outline the advantages, disadvantages and the effect of the sagittal balance on the patient function and activities. Patients and Methods: This study included a total of thirty patients who had degenerative disc disease of the cervical spine at multiple levels treated by microscopic anterior cervical decompression. The average age of participants was 43.267 ± 10.780 years (26– 64). 18 patients (60%) were females and 12 patients (40%) were males. All patients were assessed and classified before and after surgery using the neck disability index and visual analogue scale. This assessment was done for both neck and arm disability. Results: The average neck disability index at the last follow-up was 17.74 ± 2.135, which was statistically significant (P < 0.05) among groups and visual analogue scale improved from 7.4 ± 0.926 to reach 3.6 ± 0.35 six months postoperatively. Full recovery was obtained between three and six months. All patients underwent a rehabilitation protocol and found no postoperative neurological deficit in this series. Conclusions: It could be concluded that cervical sagittal imbalance arising from regional and/or global spinal sagittal malalignment plays an independent role in exacerbating adjacent segment pathomechanics after multilevel fusion and should be considered during cervical fusion surgical planning. Also, it concludes that surgery significantly led to improvement of symptoms three months post operatively.

Posterior temporary C1-2 fixation for 3-part fractures of the axis (odontoid dens and Hangman fractures).

Case series study.To report the clinical outcomes of posterior temporary C1-2 fixation for 3-part fracture of the axis (Type II odontoid fracture according to Grauer classification combined with Hangman fracture).The 3-part fracture of the axis is rare and the treatment is controversy.A total of 8 patients with 3-part fracture of the axis were included in this study. X-rays, CT, and MRI prior to surgery were used to evaluate the cervical spine injury. Grauer classification, fracture angulation, and fracture translation were used to evaluate the fracture of dens. The neck disability index (NDI) and range of neck rotary motion were used to assess the neck function.The preoperative fracture angulation and fracture translation were 4.6 ± 1.3° and 2.4 ± 0.6 mm, respectively. The average operation time and blood loss were 109 ± 27 minutes and 49 ± 15 mL. No infection, vascular injuries or neural structure injuries was observed. All patients acquired bone healing at 5.9 ± 2.0 months. The temporary instrumentation was removed at 10.8 ± 1.3 months. The average NDI before and 2 days after removal of instrumentation were 10.1 ± 4.0 and 7.1 ± 3.0, respectively. At 1-year follow-up after instrumentation removal, the NDI was 1.8 ± 0.7, which was much better than immediate NDI after instrumentation removal. The neck rotary motion (left rotation + right rotation) before and 2-day after instrumentation removal were 70.4 ± 6.3° and 119.6 ± 13.1°, respectively. At 1-year follow-up, the average neck rotary motion was 153.1 ± 9.1°, which had significant different with rotary motion 2-day after the removal of temporary instrumentation.With regard to the high fracture fusion rates, low complications, and excellent predictable outcomes in patients treated with posterior temporary C1-2 pedicle screw fixation, the technique may be a suitable choice for 3-part fracture of the axis.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P127. Redefining the cervical disability threshold of T1 slope minus cervical lordosis

BACKGROUND CONTEXT A T1 Slope minus cervical lordosis (TS-CL) angle of 20° has been described in the literature as a significant cutoff to define cervical deformity, however recent studies suggest that this cutoff needs to be redefined. PURPOSE The aim of this study was to develop a novel TS-CL threshold indicative of moderate to severe cervical disability. STUDY DESIGN/SETTING Single-center retrospective review. PATIENT SAMPLE A total of 69 cervical patients indicated for surgical treatment were included. OUTCOME MEASURES T1 slope minus cervical lordosis, neck disability index (NDI). METHODS Patients age 18years old with a primary cervical diagnosis indicated for surgical treatment were included. Patients with active infection, tumors or trauma were excluded. We tested possible cutoffs for TS-CL against the percentage of individuals meeting normative, mild, moderate (>25) and severe (>35) NDI scores at baseline. The TS-CL cutoff with the highest sensitivity to predict a normative, mild, moderate (>25) and severe (>35) NDI score was selected. RESULTS A total of 69 cervical patients indicated for surgical treatment were included (mean age 55.4±9.9years, 45% female, mean BMI 29.1±6.6 kg/m2). The average baseline NDI score was 39.9±20.9 for this cohort. At baseline, average TS-CL was 27.3°±18.8°, CL was 1.7°±17.6°, cSVA was 28.3 mm±17.3 mm. Spino-pelvic alignment parameters at baseline were as follows: PT 16.1°±8.3°, PI-LL −2.8°±11.9°, TK 38.8°±12.7° and SVA −6.3 mm±51.8 mm. Using previously established TS-CL severity breakdowns, 13 (18.8%) patients had mild TS-CL ( 20°). Using this cutoff of 20° as severe TS-CL, it did not correlate with NDI score (P=.390). After testing possible cutoffs of TS-CL that relate to moderate to severe NDI scores, a novel cutoff of 30.65° for TS-CL was related to an NDI score of ³25 points. CONCLUSIONS In a cohort of cervical surgery patients, a novel cutoff of 30.65°for TS-CL was predictive of moderate to severe neck disability, as described as an NDI score greater than or equal to 25 points. This criterion can be applied to cervical spine patients to better assess cervical disability.

Evaluating cervical deformity corrective surgery outcomes at 1-year using current patient-derived and functional measures: are they adequate?

Current health-related quality of life (HRQL) metrics used to assess patient outcomes following surgical correction of cervical deformity (CD) are not deformity-specific and thus cannot capture all aspects of a patient's deformity and outcomes. The purpose of this study is to evaluate the sensitivity of different HRQL outcome measures in assessing CD patients' outcomes 1-year post-operatively. Retrospective review of prospective multi-center database. Inclusion criteria: CD patients ≥18 yrs with pre- and 1-year post-operative radiographs and HRQLs [modified Japanese Orthopaedic Association (mJOA), EuroQol five-dimensions (EQ-5D), neck disability index (NDI)]. Associations between changes in EQ5D and NDI with improvement at 1-year in mJOA scores were assessed by whether or not the patient met the minimum clinically important difference (MCID) as well as whether or not they improved by one or more categories (i.e., change from moderate to mild). Odds ratios reported with 95% confidence intervals. Sixty-three CD patients were included (mean 62 y, 55.6% F). Average baseline NDI scores were 46.75, mJOA was 13.68, and EQ-5D 0.74. Overall baseline myelopathy breakdown: none-9.5%, mild-30.2%, moderate-42.9%, high-17.5%. At 1-year, 46% of patients improved in mJOA, 71.4% NDI, and 65.1% EQ-5D. 19% of patients met mJOA MCID, 44.4% NDI MCID, 19% EQ-5D MCID. One-point improvement in NDI increased the odds of mJOA improvement and reaching mJOA MCID (improvement: OR, 1.06, CI: 1.01-1.10, P=0.01; MCID: OR, 1.06, CI: 1.02-1.11, P=0.006). Improvement in EQ-5D by 0.1 increased the odds of improving in mJOA and reaching mJOA MCID at 1-year (improvement: OR, 3.85, CI: 1.51-9.76, P=0.005; MCID: OR, 3.88, CI: 1.52-9.88, P=0.005). While correlations exist between outcome measures, when modeling these outcomes while controlling for confounders including cSVA change, surgical invasiveness, age and CCI, these HRQLs were not strongly correlated. Improvements in functional outcomes, as defined by mJOA score, were correlated with changes in neck based disability and general health state, defined by NDI and EQ-5D respectively. In an adjusted model, however, these direct relationships were not maintained. A CD-specific HRQL might be more useful for surgeons in assessing patient outcomes using a single metric.

Effect analysis of anterior cervical operation for severe cervical kyphosis

Objective: To determine the feasibility and safety of anterior cervical decompression and fusion in severe cervical kyphosis treatment. Methods: Totally 29 patients with severe cervical kyphosis(Cobb angle>50°) underwent anterior cervical decompression and fusion from June 2008 to May 2016 were studied retrospectively. There were 19 males and 10 females. The average age was 32.6 years ranging from 14 to 53 years. According to the etiology, 12 patients had iatrogenic deformity (11 had post-laminectomy cervical kyphosis, 1 had kyphosis due to anterior graft subsidence), 5 had neurofibromatosis, 4 had infective kyphosis, 8 had idiopathic cervical kyphosis. The curvature of cervical angle was measured by two-line Cobb method. The severity of cervical kyphosis was evaluated by kyphosis index (KI). Parameters including kyphosis levels, the apex of the kyphosis, C(2-7) sagittal vertical axis(SVA) and T(1) slope were also measured on lateral radiographs in the neutral position in each patient. The pre- and post-operative Japanese Orthopaedic Association(JOA) scores, visual analogue scale (VAS) of neek pain, neck disability index (NDI) and cervical alignment were compared. All patients were treated by skull traction. Motor evoked potential and somatosensory evoked potential were applied intraoperation as the spinal cord monitor. Results: Skull traction was performed for an average of 6.3 days. The mean vertebral number in kyphotic region was 4.7. The average operation time was 155 minutes and blood loss was 135 ml. The preoperative C(2-7)Cobb angle was 46.6°±18.1° in average. It was reduced to 11.4°±6.4° in average after operation. The Cobb angle of operation region was 72.9°±19.6° in average before operation. It was reduced to 11.2°±6.4° in average after operation. The kyphosis region correction rate was 84.6%. The mean preoperative C(2-7)SVA changed from (3.8±14.6) mm to (12.6±7.8) mm postoperatively. The mean preoperative T(1) slope changed from -10.6°±16.4° to 7.1°±14.9° postoperatively. The average postoperative C(2-7) Cobb angle, Cobb angle of kyphosis region, KI, C(2-7) SVA and T(1) slope changed significantly compared with preoperation (F=12.700-218.200, all P<0.01). The average postoperative JOA, VAS and NDI scores improved significantly compared with preoperation (F=225.500, 217.900, 131.200, all P<0.01). Conclusion: For severe cervical kyphosis, anterior correction is a safe and effective technique, sufficient decompression will be achieved.

Variations in Sagittal Alignment Parameters Based on Age

Cross-sectional cohort study. Describe age-stratified normative values of traditional and novel sagittal alignment parameters. Full-body radiographic techniques can capture coronal and sagittal standing images from the occiput to the foot without stitching or vertical distortion. This provides an ideal method to evaluate measures of global alignment. Adults with no back or neck symptoms were recruited. Age, body mass index, Neck Disability Index, and Oswestry Disability Index scores were recorded. The following parameters were measured: center sacral vertebral line, Occiput-C2 (O-C2) lordosis, cervical lordosis (C2-C7, CL), thoracic kyphosis (T2-12, TK), T2-T5 kyphosis, T5-T12 kyphosis, thoracolumbar kyphosis (T10-L2), lumbar lordosis (L1-S1, LL), sacral slope, pelvic tilt, pelvic incidence (PI), knee flexion angle, global sagittal angle, T1-pelvis angle, C2-S1 sagittal vertical axis (SVA), C7-S1 SVA, Basion-C7 SVA, B-S1 SVA and Basion to the center of the femoral head SVA and PI minus LL. Comparisons of sagittal alignment parameters between different age groups were performed. A Pearson correlation was used to determine relationships. One hundred fifteen volunteers had imaging suitable for analysis; average age as 50.1 years (range 22-78), average body mass index was 28, average Neck Disability Index was 3.4 ± 4.4, and average Oswestry Disability Index was 1.7 ± 4.9. CL (r = -0.34, P = 0.001), T1-pelvis angle (r = 0.44, P < 0.001), knee flexion angle (r = 0.42, P < 0.001), global sagittal angle (r = 0.56, P < 0.001), and C7 SVA (r = 0.46, P < 0.001) all increased with age. LL decreased with age (r = 0.212, P = 0.039). We were able to establish a chain of correlation extending from the toes to the occiput and report age-based normative values for all parameters. We describe age-based normative sagittal alignment parameters in the adult spine with complete visualization from the occiput to the feet. We describe compensatory changes that occur to maintain sagittal balance. These values may be used as a reference for future studies. 4.