Mean Postoperative Japanese Orthopaedic Association Research Articles

Enhanced recovery after surgery (ERAS) program for elderly patients with short-level lumbar fusion

BackgroundDegenerative disorders of the lumbar spine decrease the mobility and quality of life of elderly patients. Lumbar fusion surgery is the primary method of treating degenerative lumbar spine disorders; however, the surgical stress response associated with major surgery has been linked to pathophysiological changes in the elderly, resulting in undesirable postoperative morbidity, complications, pain, fatigue, and extended convalescence. In the present study, we aimed to determine whether enhanced recovery after surgery significantly improved satisfaction and outcomes in elderly patients (> 65 years old) with short-level lumbar fusion.MethodsThe study enrolled lumbar disc herniation or lumbar spinal stenosis patients if they were over the age of 65 years old underwent lumbar fusion at one or two levels. Data including demographic, comorbidity, and surgical information were collected from electronic medical records. Enhanced recovery after surgery interventions was categorized as preoperative, intraoperative, and postoperative. We also evaluated primary outcome, surgical complication, length of stay, postoperative pain scores, and 30-day readmission rates.ResultsA total of 192 patients were included, 96 in the enhanced recovery after surgery group and 96 case-matched patients in the non- enhanced recovery after surgery group. There were no statistically significant intergroup differences in regards to demographics, comorbidities, American Society of Anaesthesiologists grade, or the number of fusion levels. There were also no differences between mean surgery time of intraoperative blood loss between the enhanced recovery after surgery and non- enhanced recovery after surgery groups. In addition, the mean preoperative Japanese Orthopaedic Association score, visual analog score for the back and legs, and Oswestry Disability Index score were not significantly different between the two groups. Overall, enhanced recovery after surgery pathway compliance was 92.1%. There were no significant differences in the number of complications or the mortality rates between the enhanced recovery after surgery and non-enhanced recovery after surgery groups. Furthermore, the mean postoperative Japanese Orthopaedic Association score, Visual analog score for the back and legs, Oswestry Disability Index score, and readmission rates score revealed no significant differences between the groups at 30-day follow-up point. However, we observed a statistically significant decrease in length of stay in the enhanced recovery after surgery group (12.30 ± 3.03 of enhanced recovery after surgery group versus 15.50 ± 1.88 in non- enhanced recovery after surgery group, p = 0). Multivariable linear regression showed that comorbidities (p = 0.023) and implementation of enhanced recovery after surgery program (p = 0.002) were correlated with prolonged length of stay. Multivariable logistic regression showed that no characteristics were associated with complications.ConclusionsThis report describes the first enhanced recovery after surgery protocol used in elderly patients after short-level lumbar fusion surgery. Our enhanced recovery after surgery program is safe and could help decrease length of stay in elderly patients with short-level lumbar fusion.

Anterior Controllable Antedisplacement Fusion as a Choice for Ossification of Posterior Longitudinal Ligament and Degenerative Kyphosis and Stenosis: Postoperative Morphology of Dura Mater and Probability Analysis of Epidural Hematoma Based on 63 Patients

We studied the postoperative morphology of the dura mater and analyzed the probability of epidural hematoma (EH) after anterior controllable antedisplacement and fusion (ACAF). A total of 63 patients with a diagnosis of ossification of the posterior longitudinal ligament (OPLL) and degenerative kyphosis and stenosis (DKS) had undergone ACAF from 2016 to 2017. All these patients had undergone cervical plain films, computed tomography, and magnetic resonance imaging (MRI). The operation duration, blood loss, and hospital stay were estimated. Radiological assessments included the occupying rate, OPLL type and extent, kyphotic angle, decompression width, and postoperative area of the spinal canal. On sagittal MRI, the postoperative morphology of dura mater was observed. The Japanese Orthopaedic Association scoring system was used to evaluate neurological status. EH and other surgery-related complications were recorded. Of the 63 patients, 39 had OPLL and 24 had DKS. All the patients were followed up for 3-18 months (average, 12.5). The mean decompression width and postoperative spinal canal area were 18.7 ± 1.1 mm and 167.7 ± 34.6 mm2 in the OPLL group and 17.9 ± 0.9 mm and 263.1 ± 46.9 mm2 in the DKS group, respectively. On sagittal MRI, the dura mater was classified into 4 types according to its morphology (dune, ladder, wave, and mixed type), protecting the spinal cord as would a suspensory tent. No patient presented with EH. The mean postoperative Japanese Orthopaedic Association score at the last follow-up examination was significantly better than preoperatively. The dura mater can protect the spinal cord like a suspensory tent after ACAF. The occurrence of EH is rare when ACAF is used to treat OPLL and DKS.

In Situ Decompression to Spinal Cord During Anterior Controllable Antedisplacement Fusion Treating Degenerative Kyphosis with Stenosis: Surgical Outcomes and Analysis of C5 Nerve Palsy Based on 49 Patients

To observe outcomes of anterior controllable antedisplacement fusion (ACAF) in treatment of degenerative kyphosis with stenosis (DKS) and analyze probability of C5 nerve palsy. From 2016 to 2017, a consecutive cohort of adults with DKS underwent ACAF. All patients underwent cervical radiography, computed tomography, and magnetic resonance imaging. Operative duration, blood loss, and hospital stay were estimated. Radiologic assessment included kyphotic correction, decompression width, and spinal canal area. Postoperative curvature of spinal cord was observed on sagittal magnetic resonance imaging. Japanese Orthopaedic Association score was used to evaluate neurologic status. C5 nerve palsy and other complications were recorded. The study included 49 patients. There was significant kyphosis correction postoperatively (-19.4° vs. 3.5°, P < 0.01). On cross-sectional computed tomography, mean decompression width was 19.0 mm, and spinal canal area was 218.5 mm2. On sagittal magnetic resonance imaging, spinal cord curvature was classified into 5 types: type I, lordosis; type II, straight with no shifting; type III, straight with shifting; type IV, sigmoid; and type V, kyphosis. After ACAF, the spinal cord was maintained in good curvature with no shifting in all patients. No patient presented with C5 nerve palsy. Mean postoperative Japanese Orthopaedic Association score was significantly better than preoperatively (14.9 points vs. 9.0 points, P < 0.01), with mean improvement rate of 79.8%. ACAF provides in situ decompression and good curvature to the spinal cord. Good neurologic recovery is obtained with lower incidence of C5 nerve palsy when ACAF is used to treat DKS.

Triceps-sparing ulnar approach for total elbow arthroplasty.

To prevent insufficiency of the triceps after total elbow arthroplasty, we have, since 2008, used a triceps-sparing ulnar approach. This study evaluates the clinical results and post-operative alignment of the prosthesis using this approach. We reviewed 25 elbows in 23 patients. There were five men and 18 women with a mean age of 69 years (54 to 83). There were 18 elbows with rheumatoid arthritis, six with a fracture or pseudoarthrosis and one elbow with osteoarthritis. Post-operative complications included one intra-operative fracture, one elbow with heterotopic ossification, one transient ulnar nerve palsy, and one elbow with skin necrosis, but no elbow was affected by insufficiency of the triceps. Patients were followed for a mean of 42 months (24 to 77). The mean post-operative Japanese Orthopaedic Association Elbow Score was 90.8 (51 to 100) and the mean Mayo Elbow Performance score 93.8 (65 to 100). The mean post-operative flexion/extension of the elbow was 135°/-8°. The Manual Muscle Testing score of the triceps was 5 in 23 elbows and 2 in two elbows (one patient). The mean alignment of the implants examined by 3D-CT was 2.8° pronation (standard deviation (sd) 5.5), 0.3° valgus (sd 2.7), and 0.7° extension (sd 3.2) for the humeral component, and 9.3° pronation (sd 9.7), 0.3° valgus (sd 4.0), and 8.6° extension (sd 3.1) for the ulnar component. There was no radiolucent line or loosening of the implants on the final radiographs. The triceps-sparing ulnar approach allows satisfactory alignment of the implants, is effective in preventing post-operative triceps insufficiency, and gives satisfactory short-term results.

Individualized Treatment of Complex Craniovertebral Junction Abnormalities by Intraoperative Computed Tomography and Navigation System

Background: Treatment of complex craniovertebral junction abnormalities (CCJA) with ventral cervicomedullary compression is challenging due to the aberrant anatomic structures. The exact site of the compression is usually away from the midline. The intraoperative CT and navigation system is helpful for the localization. Objective: To assess the feasibility and potential utility of this system in individualized treatment of CCJA. Methods: We applied this technology to endoscopic transnasal or microsurgical transoral odontoidectomy and/or clivusectomy in 25 cases, odontoidectomy through posterior midline approach in 1 case, and transoral C1 lateral mass resection in 1 case. The pre- and postoperative neurologic status was examined. Results: No neurovascular injury occurred during surgery. Neuronavigation was found to correlate well with the intraoperative findings. All the patients had the improvement of the presenting clinical symptoms. The mean postoperative Japanese Orthopedic Association score was 14.9, compared with the preoperative score of 10.6 (p < 0.01). One case had postoperative pulmonary infection and one case with clivusectomy had the rupture of the dura mater and leakage of cerebrospinal fluid. Conclusions: For some complicated situations of the craniovertebral junction abnormalities, the treatment strategies should be tailored and individualized and the intraoperative CT-based navigation is an effective method to be considered.