Japanese Orthopaedic Association Scoring System Research Articles

Hemilaminoplasty for the treatment of lumbar intraspinal synovial cysts (LISCs) and literature review.

The present report intended to introduce the hemilaminoplasty technique and evaluate the efficacy of our surgical procedure for LISCs. This retrospective study was conducted to analyze the results in 24 LISCs who had undergone our hemilaminoplasty between 2000 and 2012 in two hospitals. All were confirmed by pathological histology and mid- to long-term follow-up had been performed in all cases with a mean of 4.9years. Using the Japanese Orthopedic Association scoring system (JOA score) and visual analog scale (VAS), symptoms resulting from cyst compression were quantified at various stage for statistical analysis. The JOA score and VAS of back/leg pain following surgery were improved significantly (P<0.01). At final follow-up, with normal aging there was a little decrease in JOA score and VAS of back/leg pain, but still significantly improved (P<0.01). Similarly, mean improvement rate of JOA was 83.5% at 1year after surgery while 75.6% at final visit. Successful bone healing was obtained at a mean of 3.8months after surgery. No cyst reformation and recurrent back/leg pain were observed around the surgical sites. These lesions could be regarded as a result of facet arthrosis/instability and repetitive facet minor trauma with herniation of synovium through the defective joint capsule. Improvement in lumbago and leg pain may be a consequence of complete cyst resection via hemilaminoplasty plus partial facetectomy with anatomical reconstruction of the posterior spinal elements.

Posterior Hybrid Technique for Ossification of the Posterior Longitudinal Ligament Associated With Segmental Instability in the Cervical Spine

Retrospective case series. To discuss the indications for a posterior hybrid technique for ossification of the posterior longitudinal ligament (OPLL) associated with segmental instability in the cervical spine and evaluate its effectiveness and safety. Dynamic factors have been shown to play an important role in the progression of ossification and OPLL myelopathy. Laminoplasty has been widely used to treat cervical OPLL, but progressive kyphosis and progression of ossified lesions are often detected in long-term follow-up. Fifteen patients were treated by a posterior hybrid technique including laminoplasty and lateral mass screw fixation at unstable levels. Preoperatively, the extent and type of OPLL, spinal cord compression, and presence of high-intensity zones were investigated by x-ray, computed tomography, and magnetic resonance imaging. Segmental instability in the cervical spine was investigated by dynamic x-ray. Postoperatively, clinical outcomes were evaluated with the Japanese Orthopedic Association scoring system and visual analog scale scores for neck pain. Radiologic results included cervical alignment and progression of OPLL. A total of 17 intervertebral levels in 15 patients (11 mixed-type and 4 continuous-type OPLL) had segmental instability, which was consistent with the presence of high-intensity zone levels in 10 (66.7%) patients. Neurological function as evaluated by the Japanese Orthopedic Association scores was significantly improved 6 months postoperatively and well maintained 4 years postoperatively. Neck pain was significantly improved 4 years postoperatively. No patients developed progressive kyphosis or progression of ossified lesions during the follow-up. Only 1 patient developed unilateral C5 palsy and completely recovered 2 months later. This hybrid posterior technique seems to be effective and safe in the treatment of selected patients with OPLL associated with segmental instability. The potential benefits of this technique include a stable environment for spinal cord recovery and prevention of progressive kyphosis and OPLL.

Posterior lumbar interbody fusion with total facetectomy for low-dysplastic isthmic spondylolisthesis: effects of slip reduction on surgical outcomes: clinical article.

The management of isthmic spondylolisthesis remains controversial, especially with respect to reduction. There have been no reports regarding appropriate slip reduction. The purpose of this study was to investigate the following issues: (1) surgical outcomes of posterior lumbar interbody fusion (PLIF) with total facetectomy for low-dysplastic isthmic spondylolisthesis, including postoperative complications; (2) effects of slip reduction on surgical outcomes; and (3) appropriate slip reduction. A total of 106 patients who underwent PLIF with total facetectomy for low-dysplastic isthmic spondylolisthesis and who were followed for at least 2 years were reviewed. The average follow-up period was 8 years. Surgical outcomes, including the scores assessed using the Japanese Orthopaedic Association scoring system, the recovery rate, and postoperative complications were investigated. As for radiographic evaluations, pre- and postoperative slip and disc height, instrumentation failure, and fusion status were also examined. The pre- and postoperative average Japanese Orthopaedic Association scores were 14 (range 3-25) and 25 (range 11-29) points, respectively. The average recovery rate was 73% (range 0%-100%). The average pre- and postoperative slip was 24% and 10%, respectively. A significant correlation between postoperative slip and clinical outcomes was found; clinical outcomes were better in proportion to slip reduction. Although no statistical difference was detected in clinical outcomes between postoperative slip of less than 10% and from 10% to 20%, patients with postoperative slip of more than 20% showed significantly worse clinical outcomes. Postoperative complications included neurological deficits in 7 patients (transient motor loss in 6 and permanent motor loss in 1), instrumentation failures in 7, adjacent-segment degeneration in 5, and nonunion in 4. Instrumentation failures occurred significantly more often in patients with more slip reduction, although slip reduction did not affect the other postoperative complications. All patients with instrumentation failure showed postoperative slip reduction within 10%. The use of PLIF with total facetectomy for low-dysplastic isthmic spondylolisthesis appears to produce satisfactory clinical outcomes, with an average of 73% recovery rate and few postoperative complications. Although clinical outcomes were better in proportion to slip reduction, excessive reduction caused instrumentation failure, and patients with less reduction demonstrated worse clinical outcomes. Appropriate reduction resulted in a postoperative slip ranging from 10% to 20%.

Depression contributed an unsatisfactory surgery outcome among the posterior decompression of the cervical spondylotic myelopathy patients: a prospective clinical study

Posterior decompression surgery was performed on 610 patients (mean age 62 years) with clinically and radiologically defined cervical spondylotic myelopathy (CSM) at Tianjin Medical University General Hospital, between October 2007 and October 2011. After 2-year follow-up, we had a full data sets from 396 patients with normal mood or continued depression during the whole process to be compared. Depression was assessed with the 21-item Beck Depression Inventory. Physical functioning and pain were assessed with the modified Japanese Orthopedic Association (mJOA) scoring system, neck disability index (NDI), and visual analog scale (VAS). There were statistically significant differences from baseline to 2-year follow-up between normal mood (n = 258) and continuous depression (n = 138) groups in mJOA score (6.76 ± 3.12 vs. 1.42 ± 0.56, respectively; p < 0.01), VAS (23.85 ± 20.79 vs. 16.08 ± 19.76, respectively; p < 0.01), and NDI (21.11 ± 11.36 vs. 7.31 ± 2.18; p < 0.05). The adverse consequences of depression are supported by previous findings that patients with depression suffer more unsatisfactory surgery outcome than the patients with normal mood. We emphasize that patients with continuous depression show poorer improvement after posterior decompression in CSM patients with respect to symptom severity, pain intensity, and the disability score than patients without depression at any stage.

Treatment of cervical disc herniation through percutaneous minimally invasive techniques.

The goal of this study is to compare the therapeutic effectiveness of percutaneous cervical discectomy, percutaneous cervical disc nucleoplasty, and a combination of the two for the treatment of cervical disc herniation and the effective stabilization of the cervical vertebral column. A retrospective study was performed from February 2003 to April 2011. One hundred and seventy-one cervical disc herniation patients with a mean age of 47.8years (ranging from 21 to 74years) participated in the study and were treated with the three types of percutaneous minimally invasive techniques: percutaneous cervical discectomy (PCD, 97 cases), percutaneous cervical disc nucleoplasty (PCN, 50 cases), and a combination of the two (PCDN, 24 cases). After treatment, the postoperative clinical results and the stability of the cervical vertebral columns of these three groups were evaluated and compared. Patients in the PCD group received follow-up care for approximately 4.1years (ranging from 0.2 to 8.5years), while those in the PCN group received only an average of 2.6years (ranging from 0.3 to 7.8years), and the PCDN group received an average of 3.3years (ranging from 0.2 to 8years of follow-up). According to the Japanese Orthopedic Association scoring system, the functional scores (JOA scores) differed significantly between the pre- and postoperative patients within the three groups (PCD t=21.849, P=<0.05; PCN t=14.503, P<0.05; PCDN t=8.555, P<0.05). All patients had been successfully operated on by the same spinal surgeon team. According to the Odom criterion, the clinical outcomes were not significantly different for any of the three groups (the recovery rate using the JOA standard evaluation, F=2.19, P=0.116, P>0.05). The percentages of each procedure that received either an excellent or a good rating were PCD at 81.35%, PCN at 82.44% and PCDN at 83.19%. In addition, the clinical success rates among the three were not significantly different (P>0.05). Notably, there was no postoperative instability of the cervical vertebral column in any of the patients (P>0.05), and there was no difference in the pre- or postoperative stability of the cervical vertebral columns in each group. Each group achieved good clinical outcomes with this safe, minimally invasive spinal surgery for the treatment of cervical disc herniation. In addition, no postoperative risk of cervical instability was found.

Circumspinal decompression and fusion through a posterior midline incision to treat central calcified thoracolumbar disc herniation: a minimal 2-year follow-up study with reconstruction CT

PurposeThere have been several surgical approaches used in the treatment of thoracolumbar disc herniation (TLDH) from T10/11 to L1/2. However, central calcified TLDH cases are still challenging to spine surgeons. The anterior transthoracic approaches and lateral/posterolateral approaches are all essentially performed from one side; thus, the compressive lesion and the dura matter on the other side of the spinal canal are not clearly visualized, predisposing the procedure to incomplete decompression or inadvertent cord manipulation. Moreover, a number of these approaches are technically demanding and require entry into the chest. The purpose of this study was to introduce a new surgical procedure—circumspinal decompression and fusion through a posterior midline incision—for the treatment of central calcified TLDH and to evaluate its surgical outcome.MethodsIn this study, 22 patients (15 males and 7 females; mean age 49 years) with central calcified TLDH underwent this procedure between April 2008 and April 2011. Altogether, 26 discs were excised, with two discs at T10/11, eight discs at T11/12, nine discs at T12/L1 and seven discs at L1/2. Of these patients, 16 returned for final follow-up, with a mean follow-up period of 41 months (range 24–57 months). Clinical outcomes, including operative time, blood loss, perioperative complications, post-operative time of hospitalization, neurological status improvement, extent of decompression, back pain, local spinal curvature and fusion, were investigated. The patients’ neurological status was evaluated by a modified Japanese Orthopedic Association scoring system of 11 points. Fusion and the extent of decompression were evaluated by reconstruction CT at final follow-up.ResultsThe mean operative time was 185 min, the mean blood loss was 896 ml and the mean post-operative hospitalization time was 8 days. Four patients suffered perioperative complications, but only two were related to dura violation and none involved the respiratory system. All of the 16 patients who returned for the final follow-up showed improvement, and evidence of improvement was found in five of the other six patients who did not return for final follow-up through telephone interview or earlier follow-up evaluations. Complete decompression was achieved in 12 of the 16 patients who returned for final follow-up. In the 16 patients who returned for final follow-up, back pain was significantly reduced and local spinal curvature remained unaltered. In addition, based on reconstruction CT images, solid fusion was observed in 15 of the 16 patients who returned for final follow-up.ConclusionsThe circumspinal decompression and fusion through a posterior midline incision procedure can be used to treat central calcified TLDH patients with neurological deficits. This method’s greatest advantage is that it is a highly effective and safe procedure for decompression. Although it is a major and destructive procedure, spinal stability was well maintained in most of the cases. In this era when minimally invasive spine surgeries like thoracoscopy have been in an upward trajectory, spine surgeons still should be made aware of this procedure.

Diffusion tensor imaging of somatosensory tract in cervical spondylotic myelopathy and its link with electrophysiological evaluation

Background and contextAbnormal somatosensory evoked potential (SEP) (ie, prolonged latency) has been associated with poor surgical prognosis of cervical spondylotic myelopathy (CSM). PurposeTo further characterize the extent of microstructural damage to the somatosensory tract in CSM patients using diffusion tensor imaging (DTI). Study design/settingRetrospective study. Patient sampleA total of 40 volunteers (25 healthy subjects and 15 CSM patients). Outcome measuresClinical, electrophysiological, and radiological evaluations were performed using the modified Japanese Orthopedic Association (mJOA) scoring system, SEP, and cord compression ratio in anatomic magnetic resonance (MR) images, respectively. Axial diffusion MR images were taken using a pulsed gradient, spin-echo-echo-planar imaging sequence with a 3-T MR system. The diffusion indices in different regions of the spinal cord were measured. MethodsComparison of diffusion indices among healthy and myelopathic spinal cord with intact and impaired SEP responses were performed using one-way analysis of variance. ResultsIn healthy subjects, fractional anisotropy (FA) values were higher in the dorsal (0.73±0.11) and lateral columns (0.72±0.13) than in the ventral column of white matter (0.58±0.10) (eg, at C4/5) (p<.05). FA was dramatically dropped in the dorsal (0.54±0.16) and lateral columns (0.51±0.13) with little change in the ventral column (0.48±0.15) at the compressive lesions in CSM patients. There were no significant differences in the mJOA scores or cord compression ratios between CSM patients with or without abnormal SEP. However, patients with abnormal SEP showed an FA decrease in the dorsal column cephalic to the lesion (0.56±0.06) (ie, at C1/2, compared with healthy subjects [0.66±0.02]), but the same decrease was not observed for those without a SEP abnormality (0.67±0.02). ConclusionSpinal tracts were not uniformly affected in the myelopathic cervical cord. Changes in diffusion indices could delineate focal or extensive myelopathic lesions in CSM, which could account for abnormal SEP. DTI analysis of spinal tracts might provide additional information not available from conventional diagnostic tools for prognosis of CSM.

The natural clinical course of lumbar spinal stenosis: a longitudinal cohort study over a minimum of 10 years

BackgroundLittle is known about the short- and long-term prognoses of conservative treatment of lumbar spinal stenosis (LSS). Furthermore, there are no reports in the literature that investigate the relationship between longitudinal imaging changes and clinical symptoms in patients with LSS. This longitudinal cohort study aimed to clarify the morphologic changes and role of conservative treatment in LSS. MethodsThis study included 34 patients with leg or low back pain who had received a diagnosis of LSS by magnetic resonance imaging (MRI). The patients’ average age was 58years at the initial examination. All participants received conservative treatment with or without medication for over 10years. The clinical course was assessed by using the Japanese Orthopaedic Association scoring system, a visual analog scale for back or leg pain, and symptomatic Johnsson’s classification. Additionally, patients’ dural sac cross-sectional area was measured on axial MRI. ResultsOne patient could not be contacted and four others died during this investigation. After an average follow-up of 11.1years, symptoms improved in approximately 30% of patients, remained unchanged in 30%, and worsened in 30%. The dural sac cross-sectional areas in both the worsened and unchanged groups were significantly smaller than that of the improved group (P<0.05). In the worsened group, the average area at the initial examination was <50mm2. Some patients underwent surgery during this observation, and had severe narrowing (<40mm2) of the area at the initial examination. ConclusionsThis study showed that clinical symptoms of LSS did not develop in more than 60% of patients who received conservative treatment, which was dependent on the severity of LSS. In patients with severe LSS and a dural sac cross-sectional area <50mm2, the clinical course may deteriorate with conservative treatment, and surgery should be considered at an early stage.

Atlas Lateral Mass Screw Fixation in Atlanto-Axial Instability, Clinical Case Series

Background Data: Segmental spinal screw fixation has been used effectively for subaxial spine instability for long time. However, atlantoaxial fixation is still challenging due to complex topographical anatomy. So, sublaminar wires werefrequently used despite their complications. Unlike transarticular atlantoaxial screws which necessitate perfect reduction before insertion, C1 lateral mass screws are inserted independently of C2. Purpose: The aim of this work is to assess the safety and efficiency of C1 lateral mass screw fixation in cases with atlantoaxial instability. Study Design: A prospective clinical case study. Patients and Methods: This study was conducted in Al-Manial university hospital, Kasr Al-Aini Medical School, Cairo University, between 2008 and 2013. Ten patients underwent segmental atlantoaxial screw fixation using atlas lateral mass screws and either transpars interarticularis or transpedicular axis screws. Clinical results were evaluated by using the criteria of Japanese Orthopaedic Association Scoring System for Cervical Myelopathy (JOA score). The surgical technique, results and morbidity and mortality were assessed. Results: There were 6 females and 4 males; the average age was 30.2 ±17.5 y (range from 4y-61 years). The most common cause of atlantoaxial instability wastrauma (6 patients), followed by os odontoideum (2 patients ). The most common presentation was quadriparesis (5 patients) followed by neck pain and paresthesia. At the end of follow up (mean 8.5± 4.2 months) the average preoperative JOA score improved from 13.1±1.9 to 15.2±1.6 (P=0.005) and the average recovery rate was48.3±17.8%. Twenty screws were inserted in lateral mass of atlas successfully. The average screw length was 27.8±1.5mm (range 24-31mm). Postoperative CT scans showed the mean atlantodens interval improved from 5.4±1.9 to 1±1.4 (P=0.004), MRI showed that the mean cervico-medullary angle changed from 126.2°±9.4°to 141.1°±12.4° (P=0.005). There was no mortality or vertebral artery injury. One patient had profuse venous bleeding and one unit of blood was transfused and one patient had superficial wound infection and managed conservatively.Conclusion: C1 lateral mass screw fixation is a safe and effective method of atlantoaxial fixation with low complication rate. (2013ESJ052)

Comparative effectiveness of PEEK rods versus titanium alloy rods in lumbar fusion: A preliminary report

Posterior lumbar instruments made of titanium and its alloys could change the physiological distribution of load at the instrumented and adjacent segments, which is a main cause of implant failure, non-fusion and adjacent segment degeneration. Posterior lumbar rods made of polyetheretherketone (PEEK) which is a semirigid alternative to titanium and its alloys have been introduced in lumbar fusion. This prospective study compared the radiological and clinical outcomes of patients undergoing lumbar fusion with PEEK rods versus titanium alloy rods. Using transpedicular fixation and lumbar fusion, 21 patients were treated with titanium alloy rods (TI group), and 20 patients with PEEK rods (PEEK group). Radiological and clinical outcomes were evaluated, including the status of the implanted instruments, fusion rate, lumbar lordosis angle (LA), disc space height (DH), visual analog score (VAS) for lower back pain (VAS-BP) and leg pain (VAS-LP), Japanese Orthopedic Association scoring system (JOA score) and complications. Clinical VAS-BP, VAS-LP and JOA scores were significantly improved at 3 months, 6 months, and 1 year postoperatively as compared with preoperative scores in both groups (p < 0.05), with similar levels of improvement observed at the same time points postoperatively between the two groups. The overall fusion rate was 100 % at the 1-year follow-up for both groups. No significant differences in lumbar lordosis angle were found preoperatively, 1 week and 1 year postoperatively in both groups (p > 0.05). The postoperative increase of disc space height and loss of disc space height during the follow-up showed a similar extent of change between both groups (p > 0.05). PEEK rods offer a similar radiological and clinical efficacy as titanium alloy rods. PEEK rods, as a semirigid implant with unique characteristics, may be an effective alternative treatment for patients with degenerative lumbar disease in lumbar fusion.

Clinical outcomes of conservative management of spinal cord cavernous angiomas

There have been numerous studies on the outcomes of surgery for spinal cord cavernous angiomas. However, the natural history of conservatively treated disease is not well known. The aim of this retrospective study was to investigate the outcomes of conservatively managed patients with spinal cord cavernous angioma to determine the appropriate treatment strategies. Twenty-four patients who visited a single institution over an 11-year period and who were treated conservatively were enrolled in this study. Their medical records and radiological images were reviewed retrospectively. The neurologic status of the patients was assessed using the Japanese Orthopedic Association scoring system and the clinical presentation of the patients was classified into the following 4 categories: type A, asymptomatic; B, pain only; C, sensory deficits; and D, sensory and motor deficits. The results of types C and D patients were compared with the results of previously reported surgical series from our institution. The mean age of the enrolled patients was 52.0 years (21-73). The mean duration of the clinical follow-up was 60.5 months (11-119) and the follow-up using magnetic resonance imaging was 52.4 months (3-122). Cavernous angiomas presented in the cervical spinal cord in 12 patients, thoracic spinal cord in 10 patients and in multiple levels of the spinal cord in 2 patients. There were 5, 5, 7, and 7 patients, respectively, classified with types A, B, C, and D for clinical presentations. The rate of recurrent hemorrhage was 1.7 %/patient-year and all recurrent hemorrhages only developed in type C or D patients. In types C and D patients, improvement in the JOA score during the follow-up period was 0.77 ± 1.8 in the conservative group and 1.07 ± 1.8 in the surgical group (p = 0.500). However, improvement in the JOA sensory score after surgical treatment was statistically significant (P = 0.007). Conservative treatment may be a reasonable treatment strategy for patients with types A and B. If patients present with type C or D, surgical treatment is recommended considering the better improvements in sensory deficits and the high rate of recurrent hemorrhage in such patients.

Upper facet joint en bloc resection for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum

The authors introduce a novel technique to treat thoracic myelopathy caused by ossification of the ligamentum flavum (OLF): upper facet joint en bloc resection. This surgical procedure avoids surgery to the most heavily compressed cord surface, contact with the cord, and cord injury. The epidural venous plexus bleeding point can be directly seen and easily controlled during the decompression. Between January 2007 and January 2009, thoracic myelopathy caused by OLF was diagnosed in 38 patients using plain radiography, CT, and MRI, and diagnoses were confirmed by postoperative pathological examination. All upper facet joint en bloc resection procedures were performed in 2 steps. First, the bony structures above the upper facet joint surfaces were resected and the upper facet joints were isolated. Second, en bloc resection of the upper facet joint was performed by dissection of the junction between the pedicle and upper facet joint. Intraoperative neurological monitoring was performed in all cases. The modified Japanese Orthopaedic Association (mJOA) scoring system was used to assess neurological status. The degree of postoperative expansion of the spinal cord was calculated on axial MR images. The pre- and postdecompression Cobb angle was applied to assess the magnitude of local kyphosis. Of the 38 cases of OLF, 6 were single level, 12 were double level, and 20 were multilevel. Of the 92 ossified segments in this study, 23 (25.0%) were located in the upper thoracic spine (T1-4), 13 (14.1%) were located in the midthoracic spine (T5-8), and 56 (60.9%) were located in the lower thoracic spine (T9-L1). The mean intraoperative blood loss was 340 ± 54 ml. The neurological status improved during follow-up (mean 46.1 months) from a preoperative mean mJOA score of 5.39 ± 1.52 to 8.97 ± 1.22 points (t = 18.39, p < 0.05). The neurological function recovery rate ranged from 28.6% to 100%. The mean increase in pre- and postoperative kyphosis of the involved vertebrae was only 1.3° ± 1.6°. The increase in the cross-sectional area of the dural sac at the level of maximum compression suggested that decompression was complete. Upper facet joint en bloc resection is effective and may be a reasonable alternative treatment choice for thoracic myelopathy caused by OLF.

Can decompression surgery relieve low back pain in patients with lumbar spinal stenosis combined with degenerative lumbar scoliosis?

Decompression with fusion is usually recommended in patients with lumbar spinal stenosis (LSS) combined with degenerative lumbar scoliosis (DLS). However, elderly patients with LSS and DLS often have other comorbidities, and surgical treatment must be both safe and effective. The aim of this study was to investigate whether decompression surgery alone alleviates low back pain (LBP) in patients with LSS and DLS, and to identify the predictors of postoperative residual LBP. A total of 75 patients (33 males and 42 females) with a mean age of 71.8 years (range 53-86 years) who underwent decompression surgery for LSS with DLS (Cobb angle ≥ 10°) and had a minimum follow-up period of 1 year, were retrospectively reviewed using the Japanese Orthopaedic Association scoring system for the assessment of lumbar spinal diseases (JOA score). Radiographic measurements included coronal and sagittal Cobb angles, apical vertebral rotation (Nash-Moe method), and anteroposterior and lateral spondylolisthesis. Logistic regression analysis was performed to investigate the predictors of residual LBP after surgery. Forty-nine patients had preoperative LBP, of which 29 (59.1 %) experienced postoperative relief of LBP. Logistic regression analysis demonstrated that the degree of apical vertebral rotation on preoperative radiography was significantly associated with postoperative residual LBP (odds ratio, 8.16, 95 % confidence interval, 1.55-83.81, p = 0.011). A higher degree of apical vertebral rotation may therefore be an indicator of mechanical LBP in patients with LSS and DLS. Decompression with fusion should be recommended in these patients.

Myelopathy due to calcified meningiomas of the thoracic spine: minimum 3-year follow-up after surgical treatment

Calcified meningiomas are an uncommon type of meningioma. This study details the clinical features, treatment, and follow-up of 11 calcified meningiomas treated from 2002 to 2009, for the purpose of providing general information, describing the skill required for the surgery, and detailing the imaging study of these tumors. Between 2002 and 2009, 11 patients underwent surgery for the treatment of calcified meningiomas. All were treated by the same group of doctors at the same institution, including surgery and rehabilitation after surgery. The minimum 3-year (> 36 months) follow-up data from the 11 patients were detailed. Neurological function was evaluated twice, based on the Frankel scale and Japanese Orthopaedic Association scoring system. The first evaluation occurred before surgery and the second 3 years after surgery. In 3 cases, the Frankel score decreased by 1 level. In a comparison of the duration of preoperative symptoms, age, degree of canal stenosis, and intraoperative blood loss, it was found that the greater the degree of canal stenosis, the poorer the outcome of the patient. Calcified meningiomas were more likely to adhere to the nerves and dura, a finding that might explain the high incidence of neurological dysfunction and CSF leakage after surgery. Calcified meningiomas are the most rare of all meningiomas. It appears that a greater degree of canal stenosis can lead to a poorer outcome. Computed tomography scans and MRI with contrast enhancement are recommended for intraspinal tumors before surgery to exclude the possibility of calcification. For calcified meningiomas, precise tumor resection, dura repair during surgery, and medical care after surgery are important for achieving an acceptable outcome.

Application of intraoperative spinal ultrasonography in cervical laminoplasty

To investigate the clinical value of intraoperative ultrasonography in cervical laminoplasty. Thirty patients underwent cervical laminoplasty for cervical compressive myelopathy in our hospital from April 2010 to April 2012. Spinal cord compression ratio was calculated in preoperative MRI axial images for every patient. The spinal cord decompression status was evaluated by intraoperative ultrasonography during cervical laminoplasty. The pre- and post-operative Japanese Orthopaedic Association Scoring System (JOA) score was recorded, and the recovery ratios of surgery were graded using the Hirabayashi equation. The relationship between the parameters and neural recovery was explored. The intraoperative ultrasonography was used to evaluate the ventral compression of the spinal cord. The ultrasonographic dynamic viewings were classified into three types based on the spinal cord contact with ventral structures after decompression: Type 1, non-contact (n=2); Type 2, contact and apart (n=16); and Type 3, contact (n=12). The patients were divided into two groups: group A, showing Type 1 or 2 findings, representing satisfied decompression; and group B, showing Type 3 findings with insufficient decompression. The recovery ratio was (73.3±21.0)%(31.3%-100.0%) in group A, but decreased to (43.2±33.1)%(0-83.3%) in group B(t=3.05,p=0.005). Pearson analysis showed that the patient age(r=-0.294,p=0.122), preoperative JOA score(r=0.059,p=0.759), and spinal compression ratio(r=0.269,p=0.151) was not correlated with Hirabayashi recovery ratio. Intraoperative ultrasonography during laminoplasty is a feasible and promising method for evaluating spinal cord decompression status and predicting the prognosis following surgery.

Surgical Strategy for Ossification of the Posterior Longitudinal Ligament in the Cervical Spine

Ossification of the posterior longitudinal ligament is a common cause of cervical myelopathy, and controversy remains regarding surgical options. Between January 2004 and December 2007, a total of 164 patients with ossification of the posterior longitudinal ligament in the cervical spine who underwent surgical treatment at the authors' institution were included in this study. The choice of surgical option was based on pathological extent and cervical alignment. Short-segment pathology was treated via the anterior approach and long-segment pathology via the posterior approach. When the posterior approach was selected, laminoplasty was performed for the patients with cervical lordosis and laminectomy with fusion for those with cervical kyphosis. Consequently, anterior corpectomy and fusion was performed in 91 patients, laminoplasty in 41 patients, and laminectomy and instrumented fusion in 32 patients. The Japanese Orthopedic Association scoring system was used to evaluate patients' neurological status, and related complications were also recorded. Clinical results between different approaches and techniques were compared at mid-term follow-up. Based on the results of this study and a review of previous literature, no significant differences existed between different approaches and techniques for patients with mild ossification of the posterior longitudinal ligament, but anterior corpectomy and fusion had significantly better results in patients with severe ossification of the posterior longitudinal ligament. With respect to the posterior approach, laminectomy and instrumented fusion improved the surgical results of patients with cervical kyphosis, but a high incidence of C5 palsy existed simultaneously.

Clinical significance of diffusion tensor tractography as a predictor of functional recovery after laminoplasty in patients with cervical compressive myelopathy

This study was conducted to determine whether postoperative changes in the fractional anisotropy (FA) value and diffusion tensor imaging of the cervical spinal cord can predict functional outcome for patients with cervical compressive myelopathy (CCM). Twenty patients with CCM were treated by laminoplasty from 2008 to 2009. Both T2-weighted MRI and diffusion tensor imaging were performed before and after surgery. The FA values were analyzed and fiber tracking was performed. The fiber tract (FT) ratio was calculated according to the following formula: (number of fibers at the compressed level)/(number of fibers at the C-2 level) × 100%. The Japanese Orthopaedic Association scoring system for cervical myelopathy was used to determine pre- and postoperative neurological status of the patients, and the Hirabayashi method was used to calculate the recovery rate. There was no significant difference in recovery rates between patients with and those without intramedullary high signal intensity on preoperative T2-weighted images. Substantial differences in FA value among spinal cord, bone, and CSF made it difficult to obtain a precise FA value for the compressed spinal cord. There was a significant correlation between the preoperative FT ratio and the recovery rate (p = 0.0006). A poor outcome (recovery rate < 40%) could be anticipated for CCM patients with preoperative FT ratios below 60%. The preoperative FT ratio correlated significantly with the recovery rates in CCM patients. Preoperative diffusion tensor tractography can be a new prognostic predictor for neurological recovery in CCM patients after laminoplasty.

Functional outcome of surgical management of degenerative lumbar canal stenosis

Background:The long term outcomes of decompressive surgery on relief of pain and disability in degenerative lumbar canal stenosis are unclear. The aim of our study was to evaluate the outcome of surgical management of secondary degenerative lumbar canal stenosis and to analyze the effect on outcome variables using Japanese Orthopaedic Association (JOA) score.Materials and Methods:Thirty-two patients of degenerative lumbar canal stenosis managed surgically were included in this study. Laminectomy (n=2), laminectomy with disectomy (n=23), laminectomy and disectomy with instrumental stabilization (n=5), and laminectomy, disectomy with posterior interbody fusion (n=2) were performed. JOA scoring system for low backache was used to assess the patients. The recovery rate was calculated as described by Hirabayashi et al. (1981). Surgical outcome was assessed based on the recovery rate and was classified using a four-grade scale: Excellent, improvement of >90%; good, 75–89% improvement; fair, 50–74% improvement; and poor, below 49% improvement. The patients were evaluated at 3 months, one year and at last followup.Results:At 3-month followup, 18.75% patients showed excellent outcome, 62.50% patients showed good outcome, and 18.75% showed fair outcome. At 1-year followup, 64% patients showed excellent outcome and 36% patients showed good outcome. At >1 year followup (average 34.2 months, range: 2–110 months), 64% patients showed excellent outcome, 28% showed good outcome, and 8% showed fair outcome. No patient had poor outcome. Outcome of the patients improved as the time after surgery increased till 1 year and was sustained thereafter till the last followup.Conclusion:Operative treatment in patients of degenerative lumbar canal stenosis yields excellent results as observed on the basis of JOA scoring system. No patient got recurrence of symptoms of nerve compression.

Can Elderly Patients Recover Adequately After Laminoplasty? A Comparative Study of 520 Patients With Cervical Spondylotic Myelopathy

This was a prospective clinical comparative study of surgical outcomes for patients with cervical spondylotic myelopathy (CSM). The purpose of this study was to compare the surgical outcomes between nonelderly and elderly patients with CSM who underwent laminoplasty. Age at the time of surgery influences the surgical outcome. We designed a large-scale study of the surgical outcome for CSM from a single operative procedure used exclusively in elderly patients. A total of 520 consecutive patients with CSM (331 men; 189 women) who underwent double-door laminoplasty were included. Mean age was 62 years (range, 23-93), and mean duration of disease was 20.1 ± 32.0 months. Average postoperative follow-up period was 33.3 ± 15.7 months. Patients were divided into 3 groups by age: nonelderly (<65 years), young-old (65-74 years), and old-old (≥75 years). The number of patients in each group was 287, 143, and 90. Pre- and postoperative neurological status was evaluated using the Japanese Orthopaedic Association scoring system for cervical myelopathy (JOA score). Mean pre- and postoperative JOA scores in nonelderly, young-old, and old-old groups were 11.0 and 14.4, 10.2 and 13.2, and 8.7 and 11.8 points, respectively. The elderly group showed significantly low recovery rates of JOA scores compared with the nonelderly group (P < 0.0001). However, mean achieved JOA scores (postoperative JOA score - preoperative JOA score) were 3.4, 3.0, and 3.1 in nonelderly, young-old, and old-old groups, respectively, with no significant difference among these groups (P = 0.17). Pre- and postoperative JOA scores were low in elderly patients. However, the achieved JOA score was almost similar among the 3 groups. Thus, elderly patients could obtain reasonable recovery after cervical laminoplasty.

Comparison of Nurick grading system and modified Japanese Orthopaedic Association scoring system in evaluation of patients with cervical spondylotic myelopathy

The purpose of this study was to determine the correlation between Nurick grade and modified Japanese Orthopaedic Association (mJOA) scores in the preoperative and postoperative follow-up evaluation of patients with cervical spondylotic myelopathy (CSM). This retrospective study included 93 patients with CSM who underwent central corpectomy (CC) between 1998 and 2008. Preoperative and postoperative Nurick grade and total mJOA (tmJOA) and lower limb mJOA (llmJOA) score of each patient was documented and the correlation between the Nurick grades and the mJOA scores was studied. At presentation and follow-up, correlation between Nurick grade and llmJOA (Spearman's ρ 0.901 and 0.886) was better than with tmJOA (0.846 and 0.862). The Nurick grade recovery rate (NGRR) correlated better with the llmJOARR than with tmJOARR (Spearman's ρ 0.840 and 0.793, respectively). Overall, the correlation of preoperative and follow-up scores and recovery rates was better in patients with moderate myelopathy than in those with mild or severe myelopathy. At follow-up, 78/93 (83.9%) patients had improved in their Nurick grades, whereas 88/93 (94.6%) had improved in their tmJOA scores and 73/93 (78.5%) in their llmJOA scores. Although Nurick grade and llmJOA had good correlation preoperatively, at follow-up evaluation after surgery, there was disagreement in 11.8% (11/93) patients. One of the major reasons for the discrepancy between the Nurick scale and the llmJOA at follow-up evaluation was the ability of patients to regain employment without an improvement in the llmJOA score. As disease-specific scales, both Nurick scale and mJOA score should be utilized in the evaluation of patients with CSM.