Mean mJOA Score Research Articles

Surgery for deformities in pediatric spinal tuberculosis: single centre review of 51 cases.

To retrospectively report on the clinical presentation, radiological features, indication, and outcome of surgical management of children with posttubercular spinal deformities with long term outcome. This retrospective study was conducted in a single center operated by a single surgeon from 2002 to 2022, and data from an electronic medical record was reviewed. The indications for surgery included failure of medical treatment, to prevent deformity (depending on location, extent of bone loss, stabilization patterns (A, B, or C), and the presence of "Spine at Risk" signs) or correct deformity and in the presence of major neurodeficit. 51 children (< 15years) of mean age 12.5, and mean follow-up of 7years (2-15) were included. Pain, deformity/instability, and limb weakness were seen in 34 (66.6%) patients (mean mJOA score was 13.44, which improved to 14.7 and 16.8 at immediate postoperative and latest follow-up), with 17 (33.3%) patients presenting with deformity alone. Dorsal affection was commonest (60.8%), followed by lumbosacral (19.6%) and cervical (19.6%), with multilevel/skip lesions seen in four patients. The mean coronal/sagittal Cobb at presentation was 24.2°/40.96°, which improved to 8.2°/25.6° in the immediate and 8.8°/24.8° at the latest follow-up. Gene Xpert positivity was found in 95%, AFB culture positivity in 84%, and histopathology was positive in 91%. All patients had posterior surgery with an additional anterior reconstruction in 6. The complication rate was 5.8% (N = 3); 2 had implant loosening requiring revision surgery, 1 with prolonged discharging sinus with MDR TB, healed with chemotherapy. Pediatric post-tuberculous spinal deformities require identification of those who are likely to worsen, and close follow-up is mandatory. Failure of medical management, major destruction of vertebral bodies, type C stabilization pattern, and worsening deformity/neurodeficit require surgery with a good outcome.

Multiple Level Anterior Cervical Discectomy and Fusion with PEEK Cage without Plating: Clinical Outcomes

Abstract Background: Anterior cervical discectomy and fusion is a common procedure done to treat cervical disk disease. The role of plating in the treatment of multilevel disc disease in the absence of instability has been debated with some claiming no difference in the clinical outcomes. Objective: The aim of the study was to assess the long term clinical outcomes of patients who underwent two or three level discectomies with PEEK cage placement without plating. Material and Methods: We collected the required data of all patients. Patients were contacted and completed clinical outcome questionnaires including NDI and VAS-Neck. All data was tabulated and statistical analysis was done. Results: Data of 72 patients was collected. The average age of the patients was 52.73 years. The mean follow-up was 62.4 months. 37 patients presented with Myelopathy (51%), 24 with radiculopathy (33%), 11 with myeloradiculopathy. The average VAS scores for neck pain preoperatively was 6.29 (Range: 4–9) and postoperatively improved to an average of 3.18 (Range: 0–7). The average neck disability index preoperatively was 37.86 (Range: 28–47) and the average postoperative NDI score being 19.02 (Range: 9 to 28). Our patients had a preoperative mean mJOA score of 11.68 (Range:3–17) and a mean postoperative mJOA score of 14.66 (3–17) with a mean difference of 3 points. Conclusion: The clinical outcomes of multiple-level cervical fusion without plating and with plating are similar. The best surgical option is one that requires minimal disruption of normal tissue, simple in technique and provides the patient with immediate- and long-term relief.

C1-C2 coronal and sagittal joint angle based treatment algorithm for the need of transoral odointectomy in complex craniovertebral junction anomalies with Clinico-Radiological outcome analysis

Objective Craniovertebral junction (CVJ) pathology by virtue of its complexity is a surgical challenge in the realm of neurosurgery. We analyzed the need for transoral odointectomy in view of their C1-C2 joint coronal and sagittal angle of 58 patients with complex CVJ anomalies treated surgically. The clinical and radiological outcome of the patients was assessed and a treatment algorithm is proposed. Methods A total of 58 cases were included in the Prospective study over the period of 2 years. Patients were evaluated clinically, investigated, and operated with reduction and rigid internal fixation with screws and rod. The clinical outcome was measured by Modified Japanese orthopedic association score(mJOA) and radiologically by conventional craniometrics indices. Paired ‘t’ test used for statistical analysis. Results Mean age of patients: 30 years, with mean, follow up: 20.5 months. 46(80%) patients were operated by posterior and 12(20%) by combined approach (anterior transoral with posterior). Occipitocervial fixation was done in 15(25.8%) cases and C1-C2 fixation in 43(74.2%) cases. As compared to patients with low coronal angle, the patient with coronal angle >65° needed anterior decompression (87.5%) and all (100%) had Occipitocervical fixation. Clinical outcome analysis showed significant improvement in mean mJOA score (preop 11.9 Vs postop 14.6) after surgery. All craniometrics indices were significantly improved after surgery. The overall complication rate was 10% with a mortality of 1.7%. 6 months follow up completed in all patients with a 100% fusion rate. Conclusion Occipitocervical fixation and anterior decompression is required in increased C1-C2 joint CA (>65°) for bony realignment and adequate decompression. Measurement of C1-C2 joint coronal and sagittal angle in complex CVJ anomalies will easily anticipate the surgeon regarding the need for anterior decompression inform of transoral odointectomy.

Factors Predicting Poor Surgical Outcome in Patients with Thoracic Ossified Ligamentum Flavum - Analysis Of 106 Patients in a Tertiary Care Hospital in South India.

Ossified ligamentum flavum (OLF) is the major cause of thoracic myelopathy in our locality. Surgical outcomes and their related factors for patients with thoracic OLF (T-OLF) remain unclear because of the few studies on this condition. The present study aimed to examine the factors predicting poor surgical outcomes and the effectiveness of decompressive laminectomy and OLF resection in patients with T-OLF. A total of 106 patients with T-OLF operated at our institute from 2007 to 2018 were included. The mJOA score was used in neurological assessment preoperatively and during the follow-up. Multiple regression analysis was conducted to know the best correlation between factors and surgical outcomes. The mean mJOA score was 5.67 ± 2.13 preoperatively and 7.50 ± 2.60 postoperatively at the end of follow-up. The recovery rate was 43.29 ± 30.55%. After decompressive laminectomy, the mean mJOA score, modified Nurick score, and Ashworth's grade showed significant improvement (P < 0.001). Multiple regression analysis showed that the age of the patient, associated trauma, OLF level, tuberous type OLF, intramedullary signal change on T2WI, preoperative severity of myelopathy, pre-op mJOA score, and pre-op Nurick grade were significantly correlated with the surgical outcome (P < 0.001). No correlation was identified with the duration of symptoms, dural ossification, dural tear, and CSF leak (P > 0.05). It is important to identify preventable risk factors for poor surgical outcomes for T-OLF. Age of the patient, associated trauma, OLF level, tuberous type OLF, intramedullary signal change on T2WI, preoperative severity of myelopathy, preoperative mJOA score, and Nurick grade were important predictors of surgical outcome in our study series.

P91. Surgical management of octogenarians with degenerative cervical myelopathy

P91. Surgical management of octogenarians with degenerative cervical myelopathy

Long-term functional outcome of surgical treatment for degenerative cervical myelopathy.

Degenerative cervical myelopathy (DCM) is a major global cause of spinal cord dysfunction. Surgical treatment is considered a safe and effective way to improve functional outcome, although information about long-term functional outcome remains scarce despite increasing longevity. The objective of this study was to describe functional outcome 10 years after surgery for DCM. A prospective observational cohort study was undertaken in a university-affiliated neurosurgery department. All patients who underwent surgery for DCM between 2008 and 2010 as part of the multicenter Cervical Spondylotic Myelopathy International trial were included. Participants were approached for additional virtual assessment 10 years after surgery. Functional outcome was assessed according to the modified Japanese Orthopaedic Association (mJOA; scores 0-18) score at baseline and 1, 2, and 10 years after surgery. The minimal clinically important difference was defined as 1-, 2-, or 3-point improvement for mild, moderate, and severe myelopathy, respectively. Outcome was considered durable when stabilization or improvement after 2 years was maintained at 10 years. Self-evaluated effect of surgery was assessed using a 4-point Likert-like scale. Demographic, clinical, and surgical data were compared between groups that worsened and improved or remained stable using descriptive statistics. Functional outcome was compared between various time points during follow-up with linear mixed models. Of the 42 originally included patients, 37 participated at follow-up (11.9% loss to follow-up, 100% response rate). The mean patient age was 56.1 years, and 42.9% of patients were female. Surgical approaches were anterior (76.2%), posterior (21.4%), or posterior with fusion (2.4%). The mean follow-up was 10.8 years (range 10-12 years). The mean mJOA score increased significantly from 13.1 (SD 2.3) at baseline to 14.2 (SD 3.3) at 10 years (p = 0.01). A minimal clinically important difference was achieved in 54.1%, and stabilization of functional status was maintained in 75.0% in the long term. Patients who worsened were older (median 63 vs 52 years, p < 0.01) and had more comorbidities (70.0% vs 25.9%, p < 0.01). A beneficial effect of surgery was self-reported by 78.3% of patients. Surgical treatment for DCM results in satisfactory improvement of functional outcome that is maintained at 10-year follow-up.

Spinal Angiolipomas : Clinical Characteristics, Surgical Strategies and Prognosis.

ObjectiveAngiolipomas are usually found in the subcutaneous tissue of the trunk and limbs. Spinal angiolipomas (SALs) are uncommon and have rarely been reported. We report a series of nine SALs patients who received surgical treatment in our department. To summarize the clinical characteristics of SALs, propose our surgical strategies, and evaluate the effects of the operation. MethodsThis was a retrospective review of nine SALs patients who received surgical treatment from August 2015 to March 2020. Total or subtotal resection was determined by the axial localization (dorsal or ventral) and the extent of intervertebral foramen involvement. The outcomes were assessed based on the modified Japanese Orthopaedic Association (mJOA) scoring system utilized before surgery and at various follow-up points. ResultsAmong the nine patients, the mean mJOA score before surgery was 6.6±2.3, compared with 10.1±1.1 at the last follow-up time point (33.4±11.8 months). All patients achieved good outcomes, even in cases of subtotal resection. ConclusionEarly surgical resection of SALs is recommended, and the specific procedures should be determined by the axial localization (dorsal or ventral) and the extent of intervertebral foramen involvement. Most of the patients had a good prognosis, even in cases of subtotal resection.

225. Surgical outcomes in nonambulatory patients with degenerative cervical myelopathy

<h3>BACKGROUND CONTEXT</h3> Degenerative cervical myelopathy (DCM) represents a collection of age-related degenerative processes of the cervical spine that can result in motor, sensory and autonomic dysfunction, leading to significant reductions in quality of life. Individuals with severe, nonambulatory forms of DCM are often treated with spinal decompression although the extent of neurological improvement for this patient population is unclear. <h3>PURPOSE</h3> The aim of this study was to better characterize outcomes following cervical decompression in those with severe, nonambulatory forms of DCM. We believe the results of this study can be used to better inform the decision-making process when considering the potential benefits and risks of decompression surgery for these patients. <h3>STUDY DESIGN/SETTING</h3> A retrospective analysis was done on 48 patients who underwent cervical decompression surgery at University Hospitals Cleveland Medical Center between January 2007 and December 2018. <h3>PATIENT SAMPLE</h3> Patients greater than 18 years of age, with severe, nonambulatory forms of DCM classified as a Nurick grade of IV or V were included in the study. <h3>OUTCOME MEASURES</h3> Changes in Nurick and mJOA scores were used as primary outcome measures. <h3>METHODS</h3> Paired t-tests and Wilcoxon-signed rank tests were used to compare Nurick and mJOA scores before and after surgery. Patient demographics, operative details, and postsurgical complications were analyzed using descriptive statistics. <h3>RESULTS</h3> Patients experienced significant improvements in both outcomes following cervical decompression surgery. The mean Nurick grade improved from 4.10 ± 0.31 to 2.21 ± 0.82 (p < 0.001, paired t-test; 95% CI -2.08 to -1.71), while the mean mJOA score improved from 10.58 ± 1.51 to 13.60 ± 1.58 (p < 0.001, paired t-test; 95% CI 2.59 to 3.45). The average follow-up duration was 2.50 ± 1.83 years. Following surgery, 44 of the 48 patients gained the ability to ambulate without the aid of a walking frame or someone else's assistance. <h3>CONCLUSIONS</h3> Our study demonstrated that patients with severe forms of DCM experienced significant improvement in neurological function following cervical decompression surgery. These improvements indicate that cervical decompression surgery is effective in this patient population and has the potential to improve neurological status. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Single-Site Retrospective Assessment of Surgical Outcomes in Non-Ambulatory Patients with Degenerative Cervical Myelopathy.

A retrospective study of surgical outcomes in patients with degenerative cervical myelopathy (DCM). To better characterize outcomes following cervical decompression in those with severe, non-ambulatory forms of DCM. DCM represents a collection of age-related degenerative processes of the cervical spine that can result in motor, sensory, and autonomic dysfunction, leading to significant reductions in quality of life. Individuals with severe, non-ambulatory forms of DCM are often treated with spinal decompression although the extent of neurological improvement for this patient population is unclear. A retrospective analysis of 48 non-consecutive non-ambulatory patients who underwent cervical decompression surgery between January 2007 and December 2018. Paired t tests and Wilcoxon signed rank tests were used to compare Nurick grade and modified Japanese Orthopedic Association (mJOA) score before and after surgery. Patient demographics, operative details, and postsurgical complications were analyzed using descriptive statistics. Patients experienced significant improvements in both Nurick grade and mJOA score following cervical decompression surgery. The mean Nurick grade improved from 4.10 ± 0.31 to 2.21 ± 0.82 (P < 0.001, paired t test; 95% confidence interval [CI] -2.08 to -1.71), while the mean mJOA score improved from 10.58 ± 1.51 to 13.60 ± 1.58 (P < 0.001, paired t test; 95% CI 2.59-3.45). The average follow-up duration was 2.50 ± 1.83 years. Following surgery, 44 of the 48 patients in the study gained the ability to ambulate without the aid of a walking frame or someone else's assistance. This study demonstrated that patients with severe forms of DCM experienced significant improvement in neurological function following cervical decompression surgery. These improvements indicate that cervical decompression surgery is effective in this patient population and has the potential to improve neurological status.Level of Evidence: 3.

Cervical Hemilaminectomy in the Management of Degenerative Cervical Spine Myelopathy

Introduction: Hemilaminectomy is one of the surgical options for managing cervical spondylotic myelopathy. However, it has not gained the expected popularity. This paper aims to review the utilization of hemilaminectomy, the outcome, and complications observed among patients managed with the procedure for advanced multilevel degenerative cervical myelopathy. Methods: Retrospective longitudinal analysis was done at a neurosurgical hospital in Enugu, Nigeria, between years 2010 and 2019. The Study analyzed 46 patients that had cervical hemilaminectomy for multilevel degenerative cervical myelopathy. Excluded from the study were patients offered cervical hemilaminectomy for other indications including tumor and trauma. Patients were assessed by comparing preoperative, and follow-up modified Japanese Orthopedic Association (mJOA) score and Cobb lordotic angles. The minimum postoperative follow-up period was for 1 year. Results: The mean age was 61 (43–88) years; male-to-female ratio was 3.6:1. Symptoms duration ranged from 6 months to 10 years, and 31 (67.4%) patients had significant comorbidities. The average operation time was 2 h 36 min (0.5–3.0 h). The mean blood loss was 260 mL (100–800 mL). Right hemilaminectomy was done for 37 (80.4%) patients. The average preoperative and postoperative Cobb lordotic angles were 10.90° ± 2.4° and 9.98° ± 2.1°. The mean preoperative mJOA was 8.2 ± 1.4. On follow-up 1 year after surgery, the mean mJOA score was 12.2 ± 1.1 (P = 0.0001). The neurological recovery rate at 1-year follow-up was 50.5%. One patient each experienced a transient postoperative drop in neurology, postoperative respiratory distress, and surgical site infection. Conclusion: Cervical hemilaminectomy for multilevel degenerative cervical spine myelopathy has the potential to achieve clinically satisfactory neurological improvement without significantly compromising stability and other serious long-term complications.

Transthoracic microsurgical anterior decompression without fusion for ossification of the posterior longitudinal ligament in the thoracic spine

OBJECTIVEThe authors aimed to analyze outcomes following transthoracic microsurgical anterior decompression of thoracic ossification of the posterior longitudinal ligament (T-OPLL), which was causing myelopathy, and determine the predictive factors for surgical outcomes.METHODSPatients who underwent transthoracic microsurgical anterior decompression without fusion for the treatment of T-OPLL from December 2014 to May 2019 were included. Demographic, radiological, and perioperative data and clinical outcomes of 35 patients were analyzed. The modified Japanese Orthopaedic Association (mJOA) score and recovery rate were used to evaluate functional outcomes.RESULTSA total of 35 consecutive patients (8 men and 27 women; mean age 52.2 ± 10.8 years) were enrolled in this study, and the mean follow-up period was 65.5 ± 51.9 months. The mean mJOA score significantly improved after surgery (5.9 ± 1.8 vs 8.3 ± 1.5, p &lt; 0.001), with a mean recovery rate of 47.7% ± 24.5%. The visual analog scale (VAS) score significantly improved after surgery (7.3 ± 1.3 vs 4.3 ± 0.7, p &lt; 0.001). The outcome was excellent in 4 patients (11.4%), good in 21 patients (60.0%), fair in 4 patients (11.4%), unchanged in 5 patients (14.3%), and worsened in 1 patient (2.9%). There were 12 cases of CSF leakage, 1 case of epidural hematoma, 1 case of pleural effusion, and 1 case of pneumothorax. Age, preoperative kyphotic angle, anteroposterior length of T-OPLL at the maximally affected level, and mass occupying rate were identified as predictors associated with postoperative outcome. A multivariate regression analysis revealed that age and preoperative kyphotic angle were independent risk factors for postoperative outcomes.CONCLUSIONSTransthoracic microsurgical anterior decompression without fusion achieved favorable clinical and radiological outcomes for treating T-OPLL with myelopathy. Patient age and preoperative kyphotic angle were independent risk factors for lower recovery rate.

Surgical outcomes of posterior occipito-cervical decompression and fusion for basilar invagination: A prospective study

Study designA Prospective Study. ObjectiveTo assess results of posterior occipito-cervical decompression and fusion operated with intra-operative traction/manipulation and instrumented reduction in cases of Basilar Invagination(BI). MethodsTotal 22 patients of 8–65 years with diagnosed BI were operated for posterior occipito-cervical fusion by intra-operative traction/manipulation and instrumented reduction. Fusion was done using autologous bone graft taken from iliac crest. Immediate post-operative, first month and then every 3 months’ follow-up examination were done for minimum period of 2 years. Results22 patients (10 males,12 females) with mean age of 23.9 years having BI were included. 11 patients had C1 occipitalization, 4 had platybasia and 9 had atlanto-axial dislocation (AAD). 1 patient with os odontoideum with kyphotic deformity expired on 4th postoperative day due to respiratory insufficiency (mortality rate 4.54%). Neurological improvement by at least by one grade according to RANAWAT’s and/or NURICK’S scale was observed in 17/21 patients (80.95%). 3 patients remained static and 1 had neuro-worsening. Mean mJOA score of 13.14 improved to 16.24. All had reduction of dens below foramen magnum according to McRae, chamberlain line and Ranawat index. Bone graft fused in all patients as confirmed with CT scan and dynamic X-rays. 1 wound dehiscence and 1 asymptomatic implant loosening were seen on follow-up. ConclusionSurgical treatment of BI with intra-operative traction/manipulation, instrumented reduction and posterior occipito-cervical fusion can achieve good correction of radiology, functional performance and clinical neurology as well as excellent fusion rates without adverse effects of trans-oral surgery.

101. Prospective evaluation of degenerative cervical myelopathy in asymptomatic patients over 60 years

BACKGROUND CONTEXT Degenerative cervical myelopathy (DCM) is caused by narrowing of the cervical spinal canal resulting in compression of the spinal cord. The diagnosis of DCM is confirmed by history, physical exam findings, and advanced imaging showing cord compression. Radcliff et al reported the incidence of undiagnosed DCM in hip fracture patients (18%) and elective hip replacement patients (0%) based on history, modified Japanese Orthopedic Association (mJOA) score, and physical exam. Other investigators have studied the specificity and sensitivity of physical exam findings for diagnosing DCM and found it to be imperfect, with 21% of patients diagnosed with DCM lacking obvious clinical signs. PURPOSE The purpose of this study was to determine the prevalence of undiagnosed DCM in patients over 60 years by combining history, physical exam, and MRI. STUDY DESIGN/SETTING Prospective case series. PATIENT SAMPLE Patients aged 60 years or older without history or current symptoms of DCM. OUTCOME MEASURES Central canal stenosis as measured by MRI, myelopathic symptoms on neurologic exam, and patient-reported outcomes (mJOA and neck disability index [NDI]). METHODS Patients 60 years and older were prospectively enrolled from primary care practices. Patients were excluded if they had a history of debilitating neck pain, inability to have a cervical MRI, neurologic disease, cognitive impairment, or prior cervical spine surgery. A cervical MRI was performed using a 3.0 Tesla imaging system and a cervical coil. NDI and mJOA scores were collected for all patients, as well as a thorough history and physical exam. MRI results were reviewed independently by an orthopedic spine surgeon and neuroradiologist. Central cervical canal stenosis was graded 0-3, with 0 indicating no canal stenosis and 3 indicating spinal cord compression with myelomalacia. Patients were diagnosed with DCM if they had myelopathic history (mJOA RESULTS Eighty patients were included in the study: 39 Males (48.8%) and 41 Females (51.2%). The average age was 68.6 years-old (range 60–90 years). The mean NDI was 2.5%, range 0-24%. The mean mJOA score for the cohort was 17.5 (range 14-18). Two patients (3.8%) had an mJOA score of 16. Two (2.5%) patients had myelomalacia on MRI but were asymptomatic. CONCLUSIONS In our study, the prevalence of cervical spinal cord compression in patients 60 years and older with minimal neck pain was found by MRI to be 37.5%. Among these patients, one was diagnosed with DCM, while two others had myelomalacia with a normal physical exam. Our data support the work of other researchers and show that patients may have MRI findings of myelomalacia but remain asymptomatic. This study confirms a small but important prevalence of spinal stenosis and spinal cord compression in patients over 60 who have minimal or no symptoms. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Surgical complications associated with multilevel anterior cervical decompression and fusion technique in a large prospective study

This study describes our experience with the treatment of cervical degenerative pathology through anterior cervical decompression and fusion technique. We evaluated the clinical outcome and complications after 6-months follow-up and analysed the data to optimize the efficacy and safety of this particular surgical treatment in order to minimize the risks of complications. The presented study included 111 patients (74 men and 37 women; mean age 56.5 years) treated in the Neurosurgical Department of UMBAL Sv. Ivan Rilski Hospital in Sofia, Bulgaria, for cervical degenerative multilevel pathology with myelopathy. The operations included only anterior cervical approach with single-level or multilevel corpectomy, considering the pathology and neurological deficit in each particular case, followed by instrumented fusion with titanium mesh and locking plates. We analysed the data for intraoperative, early and late postoperative complications and the neurological results were examined and compared with the aid of Nurick and mJOA scales for myelopathy. The mean mJOA score preoperatively was 11.37 (SD ± 2.63) and postoperatively the mean mJOA score was 13.27 (SD ± 2.61), p < 0.0001. Since the emerging of this technique more than 50 years ago, it has improved in many ways, although there are still some contradictory results. Still, the most important aspect should be to consider the individual’s pathology in order to better understand the underlying problems and think of ways to resolve them appropriately.

Degenerative Cervical Myelopathy in Higher-Aged Patients: How Do They Benefit from Surgery?

Background: Degenerative cervical myelopathy (DCM) is the most common reason for spinal cord disease in elderly patients. This study analyzes the preoperative status and postoperative outcome of higher-aged patients in comparison to young and elderly patients in order to determine the benefit to those patients from DCM surgery. Methods: A retrospective analysis of the clinical data, radiological findings, and operative reports of 411 patients treated surgically between 2007 and 2016 suffering from DCM was performed. The preoperative and postoperative neurological functions were evaluated using the modified Japanese Orthopedic Association Score (mJOA Score), the postoperative mJOA Score improvement, the neurological recovery rate (NRR) of the mJOA Score, and the minimum clinically important difference (MCID). The Charlson Comorbidity Index (CCI) was used to evaluate the impact of comorbidities on the preoperative and postoperative mJOA Score. The comparisons were performed between the following age groups: G1: ≤50 years, G2: 51–70 years, and G3: >70 years. Results: The preoperative and postoperative mJOA Score was significantly lower in G3 than in G2 and G1 (p < 0.0001). However, the mean mJOA Score’s improvement did not differ significantly (p = 0.81) between those groups six months after surgery (G1: 1.99 ± 1.04, G2: 2.01 ± 1.04, G: 2.00 ± 0.91). Furthermore, the MCID showed a significant improvement in every age-group. The CCI was evaluated for each age-group, showing a statistically significant group effect (p < 0.0001). Analysis of variance revealed a significant group effect on the delay (weeks) between symptom onset and surgery (p = 0.003). The duration of the stay at the hospital did differ significantly between the age groups (p < 0.0001). Conclusion: Preoperative and postoperative mJOA Scores, but not the extent of postoperative improvement, are affected by the patients’ age. Therefore, patients should be considered for DCM surgery regardless of their age.

Clinical and magnetic resonance imaging predictors of the surgical outcomes of patients with cervical spondylotic myelopathy

ObjectiveTo determine whether clinical characteristics and signal and morphologic changes on magnetic resonance (MR) images of the spinal cord (SC) are associated with surgical outcomes for cervical spondylotic myelopathy (CSM). Patients and MethodsA total of 113 consecutive patients with cervical myelopathy underwent cervical decompression surgery in our hospital from January 2015 to January 2018. All patients with preoperative MR images available for review were recruited for this study. Research data included patient sex, age, duration of symptoms, surgical approach, compression level, preoperative mJOA (modified Japanese Orthopaedic Association) score, postoperative mJOA recovery rate, and complications. Imaging data included signal changes on T2-weighted MRI images (grade and extension on sagittal images, four types of signal changes on axial images according to the Ax-CCM system), SC compression, transverse area of the SC, and compression ratio. The t-test, Mann–Whitney U-test, Kruskal–Wallis H - test, analysis of variance, and regression analysis were used to evaluate the effects of individual predictors on surgical outcomes. ResultsThe study cohort included 85 males and 27 females with a mean age of 60.92 ± 8.93 years. The mean mJOA score improved from 10.24 ± 1.69 preoperatively to 15.11 ± 2.05 at the final follow-up (p < 0.001). Patients in the poor outcome group were more likely to present with a longer duration of symptoms (p < 0.001) and smaller transverse area of the SC (p < 0.001). Bright T2-weighted high signal changes (T2HSCs), multisegmental high signal changes on sagittal MR images, and fuzzy focal T2HSCs on axial MR images were associated with a poor outcome (p < 0.001, p = 0.005, p < 0.001, respectively). The maximum SC compression and compression ratio were not reliable predictors of surgical outcomes (p = 0.375, p = 0.055, respectively). The result of multivariate stepwise logistic regression showed that a longer duration of symptoms, multisegmental T2HSCs on sagittal MR images and fuzzy focal T2HSCs on axial MR images were significant risk factors of poor outcomes (p < 0.001, p = 0.049, p = 0.016, respectively). ConclusionA longer duration of symptom, multisegmental T2HSCs on sagittal MR images, and fuzzy focal T2HSCs on axial MR images were highly predictive of a poor surgical outcome for CSM. Smaller transverse area of the SC and bright T2HSCs were also associated with the prognosis of CSM.

Wednesday, September 26, 2018 1:00 PM – 2:00 PM Spinal Trauma: 55. Aggravation of spinal cord compromise following new osteoporotic vertebral compression fracture prevented by teriparatide in patients with surgical contraindications

BACKGROUND CONTEXT Osteoporotic fractures occur frequently in people over 50 years of age, with prevalence of 40%–50% in women and 13%–22% in men, among which osteoporotic vertebral compression fracture (OVCF) is the most common type. Although a large percentage of OVCFs are stable, the unstable OVCFs are not rare. Compared with the stable OVCFs, the unstable OVCFs could associate with neurological deficits and lead to higher morbidity and mortality. The unstable OVCFs usually are not candidates for cement-augmentation treatment, and the neurological deficits may aggravate after the traditional nonoperative treatment. Open surgery, which decompresses the spinal cord and stabilizes the fractured vertebrae by implanted instruments, is a potential option for the unstable OVCF to prevent further spinal cord compromise. However, if they have severe bone fragility or comorbid medical problems, decompression and instrument implantation surgeries are contraindicated. Teriparatide (Forteo, Eli Lilly and Co. Indianapolis, IN, USA) is the first bone anabolic drug approved by the US Food and Drug Administration for reducing the incidence of osteoporotic fracture. Recently, teriparatide has been shown to produce significant improvement of bone strength by improving bone turnover and bone mineral density (BMD). Lately, Park et al have applied teriparatide in treatment of the stable OVCF and found that short-term teriparatide treatment could decrease the progression of the fractured vertebral body collapse. In the present study, patients with neurological deficits following new unstable OVCF and with surgical contraindications were randomized into two groups receiving teriparatide/alendronate. We evaluated whether teriparatide can prevent the further fractured vertebral body collapse and prevent aggravation of spinal cord compromise in unstable OVCF. We hypothesized that conservative treatment with teriparatide would improve bone turnover parameters and BMD to strengthen the fractured vertebrae to be stabilized, as well as prevent aggravation of the spinal cord compromise. PURPOSE This study compared the preventive effects of teriparatide and alendronate on aggravation of spinal cord compromise following new unstable -OVCF- in patients with surgical contraindications. STUDY DESIGN/SETTING This was a 12-month, randomized, open-label study of teriparatide versus alendronate in 49 patients with new unstable OVCF and surgical contraindications. Neurological function was evaluated using modified Japanese Orthopedic Association (mJOA) score (11-point scale, the maximum score of 11 implies normalcy). Visual analog scale (VAS) scores, kyphotic angles, anterior-border heights and diameters of the spinal canal of the fractured vertebrae, any incident of new OVCFs (onset of OVCF during follow-up), spine bone mineral density (BMD), and serum markers of bone resorption and bone formation were also examined at baseline and 1, 3, 6, and 12 months after initiation of the medication regimen. PATIENT SAMPLE This was a 12-month, open-label, randomized controlled trial, conducted at our center, which compared the effects of teriparatide (Forteo, Eli Lilly, Indianapolis, IN, USA) and alendronate (Fosamax, Merck & Co., Kenilworth, NJ, USA) on patients with neurological deficits following new unstable OVCF and with surgical contraindications. From September 2012 to August 2014, we prospectively selected inpatients and outpatients who presented to our center with osteoporosis and new OVCF between T1 and L1. Inclusion criteria were female sex, age 60-80 years, new fracture within 3 weeks, single-level fracture without burst component, associated neurological deficit, L2–L4 BMD Tscore ≤−2.5, severe bone fragility (low BMD, ie, OUTCOME MEASURES Statistical analysis was performed using SPSS Statistics for Windows, Version 17.0 (SPSS Inc., Chicago, IL, USA). Results are presented as mean ± standard deviation. Depending on the normality of the data, the independent sample t test and Mann-Whitney U test were used to compare parameters between the two groups, while a paired t test was performed to analyze intra-group differences. Significance was accepted for a P value of RESULTS At 12 months, mean mJOA score had improved in the teriparatide group and decreased in the alendronate group. Mean concentrations of bone formation and bone resorption biomarkers, mean spine BMD, and mean anterior-border height and spinal canal diameter of the fractured vertebrae were significantly greater in the teriparatide group than in the alendronate group. Mean VAS score, mean kyphotic angle of the fractured vertebrae, and incidence of new OVCFs were significantly smaller in the teriparatide group than in the alendronate group. CONCLUSIONS In patients with neurological deficits following new unstable OVCF and with surgical contraindications, teriparatide was better than alendronate at improving the BMD and the bone turnover parameters, as well as preventing aggravation of spinal cord compromise. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Outcome factors in surgically treated patients for cervical spondylotic myelopathy

Context/Objective: To investigate prospectively preoperative parameters that might be related to the outcome of surgically treated patients for cervical spondylotic myelopathy (CSM).Design: Prospective study.Setting: Single Center in Ioannina, Greece.Participants: Thirty-six patients were included in the study. There were 21 males and 15 females, mean age 50.8 years, range 39–70 years. The mean BMI was 27.3.Outcome measures: From each patient, we recorded age, sex, BMI, symptoms, duration of symptoms, comorbidities, lifestyle, myelopathy grade based on MRI and levels of compression. All patients completed the modified JOA (mJOA) and NPE questionnaires preoperatively and at 1, 3, 12 months and 5-years postoperatively.Results: The mean mJOA score significant improved from 10.8 ± 1.9 points preoperatively to 16.6 ± 2.2 points at 12 months postoperatively. The mean mJOA score at 5-years postoperatively was 15.5 ± 3 points. The difference was still highly significant. The mean NPE score significant improved from 59.8 ± 12.2 points preoperatively to 28.2 ± 8.5 points at 1 month, to 35.8 ± 8.1 points at 3 month and to 28.2 ± 8.8 points at 12 months postoperatively. Younger patients had significant higher baseline mJOA scores and significant higher mJOA scores 5-year postoperatively. No correlation was found between sex, BMI, symptom duration, baseline mJOA or myelopathy grade and outcome at 12 months or 5-year postoperatively.Conclusion: Age was highly predictive factor of outcome for patients undergoing surgical treatment of CSM.

Aggravation of spinal cord compromise following new osteoporotic vertebral compression fracture prevented by teriparatide in patients with surgical contraindications.

This study compared the preventive effects of teriparatide and alendronate on aggravation of spinal cord compromise following new unstable osteoporotic vertebral compression fracture (OVCF) in patients with surgical contraindications. This was a 12-month, randomized, open-label study of teriparatide versus alendronate in 49 patients with new unstable OVCF and surgical contraindications. Neurological function was evaluated using modified Japanese Orthopedic Association (mJOA) score (11-point scale, the maximum score of 11 implies normalcy). Visual analog scale (VAS) scores, kyphotic angles, anterior-border heights and diameters of the spinal canal of the fractured vertebrae, any incident of new OVCFs (onset of OVCF during follow-up), spine bone mineral density (BMD), and serum markers of bone resorption and bone formation were also examined at baseline and 1, 3, 6, and 12months after initiation of the medication regimen. At 12months, mean mJOA score had improved in the teriparatide group and decreased in the alendronate group. Mean concentrations of bone formation and bone resorption biomarkers, mean spine BMD, and mean anterior-border height and spinal canal diameter of the fractured vertebrae were significantly greater in the teriparatide group than in the alendronate group. Mean VAS score, mean kyphotic angle of the fractured vertebrae, and incidence of new OVCFs were significantly smaller in the teriparatide group than in the alendronate group. In patients with neurological deficits following new unstable OVCF and with surgical contraindications, teriparatide was better than alendronate at improving the BMD and the bone turnover parameters, as well as preventing aggravation of spinal cord compromise.

Thinning, Peeling and Carving Technique for the Treatment of Thoracic Myelopathy Caused by Ossification of Ligamentum Flavum

Introduction To introduce a novel technique of thinning, peeling and carving to remove the ossification ligamentum flavum(OLF) nidus easily, safely and completely for the treatment of thoracic myelopathy caused by OLF. This surgical procedure avoids aggressive irritating the most seriously compressed spinal cord caused by OLF nidus especially. The epidural venous plexus bleeding and the bleeding from the pedicle can be seen clearly and controlled easily during the decompression. Material and Methods Thoracic myelopathy caused by OLF was diagnosed in 28 patients using plain radiography, 3D CT, and MRI from January 2009 to January 2012. The lamina, the lower and the upper facet joint of the involved segment were thinned with the bigger neuro drill(diameter 3.5mm) first, The shell was so thin that the feeding blood vessels of the dura can be seen clearly. Second, the thinned shell was peeled off with the curette piece by piece. The upper facet joint and the OLF nidus were carved by the smaller neuro drill (diameter 2.5mm)and the thinned bony nidus compressing the spinal cord was removed finally, Spinal cord monitoring (SEP and MEP)was performed intraoperatively in all cases. The operating time and blood loss were recorded during the operation. The Frankel scoring system was used to assess the neurological status before the operation and in the follow up. The S F-36 were also used to assess the general health status. Results Of the 28 cases of OLF,3 were single level, 10 were double level, and 15 were multilevel. Of the 71 ossified segments in this study, 16 (22.5%) were located in the upper thoracic spine (T1–4), 9 (12.7%) were located in the midthoracic spine (T5–8), and 46 (64.8%) were located in the lower thoracic spine (T9-L1). The mean operating time was 145 ±32min. The mean intraoperative blood loss was 280 ± 48.6 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 &lt; 0.05). The neurological function recovery rate ranged from 28.6% to 100%. Conclusion Thinning, peeling and carving technique was effective, safe and may be a reasonable choice for the treatment of thoracic myelopath y caused by OLF