Posterior Approach In Patients Research Articles

The SAInT study: a protocol for a randomized controlled trial of steroid injection for subacromial pain syndrome using the anterolateral versus posterior approach.

Steroid injections are used for subacromial pain syndrome and can be administered via the anterolateral or posterior approach to the subacromial space. It is not currently known which approach is superior in terms of improving clinical symptoms and function. This is the protocol for a randomized controlled trial (RCT) to compare the clinical effectiveness of a steroid injection given via the anterolateral or the posterior approach to the subacromial space. The Subacromial Approach Injection Trial (SAInT) study is a single-centre, parallel, two-arm RCT. Participants will be allocated on a 1:1 basis to a subacromial steroid injection via either the anterolateral or the posterior approach to the subacromial space. Participants in both trial arms will then receive physiotherapy as standard of care for subacromial pain syndrome. The primary analysis will compare the change in Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include the change in OSS at six and 12 months, as well as the Pain Numeric Rating Scale (0 = no pain, 10 = worst pain), Disabilities of Arm, Shoulder and Hand questionnaire (DASH), and 36-Item Short-Form Health Survey (SF-36) (RAND) at three months, six months, and one year after injection. Assessment of pain experienced during the injection will also be determined. A minimum of 86 patients will be recruited to obtain an 80% power to detect a minimally important difference of six points on the OSS change between the groups at three months after injection. The results of this trial will demonstrate if there is a difference in shoulder pain and function after a subacromial space steroid injection between the anterolateral versus posterior approach in patients with subacromial pain syndrome. This will help to guide treatment for patients with subacromial pain syndrome.

No difference in early functional outcome between the direct anterior approach and posterior approach in patients following total hip arthroplasty.

Objective and subjective outcomes in the direct anterior approach (DAA) and posterior approach (PA) in total hip arthroplasty (THA) were assessed in this study, using the Oxford Hip Score (OHS) as primary outcome. Pain, 3 objective performance-based tests, surgical time, blood loss and length of stay were assessed as secondary outcomes. Patients with primary end-stage osteoarthritis were prospectively enrolled by shared decision making for the DAA (32 patients) or PA (26 patients). Baseline data were collected preoperatively and outcomes postoperatively at 2-, 6-, 9- and 12-month follow-up. There is no significant difference (p < 0.05) between the DAA and PA on primary outcome (OHS). There was a main effect of time which indicated an increase of OHS over time independent of group (p < 0.01). In the current study, no significant differences in postoperative functional outcome were found between DAA and PA in all follow-up moments.

Outcome of Dual Stability and Decompression through Single Posterior Approach in Tuberculosis of Dorsolumbar Spine

Objective: To evaluate the outcome of dual stability and decompression through a single posterior approach in patients with tuberculosis of the dorsolumbar spine in terms of Oswestry Disability Index and Frankel Neurological Grading. Material and Methods: It was a prospective cohort study involving 34 patients with tuberculosis of the dorsolumbar spine who underwent dual stability and decompression through a single posterior approach. Follow-ups were done at 2nd, 6th, 12th and 16th weeks. The outcome was assessed using the Oswestry Disability Index and Frankel Neurological Grading. Results: In 34 patients, the mean age was 36.59±13.51 years. There were 20 (58.8%) males and 14 (41.2%) females. There were 9 (26.5%) patients who had dorsal spine tuberculosis, while lumbar spine TB and dorso-lumbar spine TB were diagnosed in 13 (38.2%) and 12 (35.3%) patients respectively. The mean surgery time was 4.20±0.66 hours. According to the Oswestry Disability Index, before surgery, 2 (5.9%) patients had minimal disability while after 16 weeks of follow-ups, these numbers increased to 23 (67.7%) showing statistically significant improvements. According to Frankel Neurological Grading, before surgery, 3 (8.8%) patients had normal function while after 20 weeks of follow-up following surgery, 20 (58.9%) had normal functions. Conclusion: Dual stability and decompression through a single posterior approach were found to have good functional and fusion outcomes according to the Oswestry Disability Index and Frankel Neurological grading.

Medium-term outcomes of laparoscopic pubocervical fascia reconstruction and sacrospinous ligament fixation with posterior approach for a pelvic organ prolapse: A retrospective study of 124 cases

ObjectivePelvic organ prolapse (POP) is a common gynecological disease in middle-aged and older women that seriously affects patients' physical health and quality of life, increases the financial burden for patients, and becomes a major public health concern. The aim of this study was to investigate the medium-term outcomes of laparoscopic pubocervical fascia reconstruction and sacrospinous ligament fixation with a posterior approach for patients with severe POP. MethodsPatients with severe POP quantitation stage III–IV who underwent laparoscopic pubocervical fascia reconstruction and sacrospinous ligament fixation with a posterior approach at the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine between September 2016 and December 2020 were enrolled in this study. The results and complications were recorded. Data were retrospectively reviewed. ResultsIn total, 124 patients were analyzed. Patients were followed up for 32.27 ± 12.90 months. The objective cure rate for patients who underwent hysterectomy was 91.7% (100/109), with 7 (6.4%) patients had anterior vaginal wall prolapse and 2 (1.8%) patients had posterior vaginal wall prolapse. The objective cure rate for patients who retained uterus was 66.7% (10/15). All 5 patients with recurrence had uterine prolapse, and 3 (20.0%) of them also had anterior vaginal wall prolapse. ConclusionsLaparoscopic pubocervical fascia reconstruction and sacrospinous ligament fixation with the posterior approach is a safe, minimally invasive, and effective method for patients with severe POP. Long-term follow-up is needed to confirm the clinical effects.

Anterior approach versus posterior approach for the open reduction of displaced pediatric supracondylar humerus fracture

BackgroundThis study's objective was to compare the results and adverse outcomes of the anterior approach and posterior approach in patients with a type 3 Gartland pediatric supracondylar fracture who failed close treatment and indicated open reduction. Methodsin this retrospective study patients with Gartland type 3 fracture who failed close reduction and required open reduction were enrolled in the study. Eligible patients underwent open reduction via anterior and posterior triceps sparing approaches. Patients were followed up 3, 6, and 12 months after the surgery. Study variables included age, sex, Bauman's angle, pin site infection, nerve injury, osteonecrosis, and elbow arc of motion. ResultsThe study included a total of 83 patients. Surgery was performed on 49 patients using the posterior technique and 34 patients using the anterior approach. The mean age of patients was 6.78 ± 1.40 years. The mean age and the relative frequency of sex didn't differ significantly between study groups (P > 0.05). Two-way repeated measures ANOVA test showed that there was a statistically significant difference in elbow arc of motion in the anterior approach in comparison with the posterior approach, however, this increase was not clinically significant. In terms of adverse events including pin site infection, nerve injury, osteonecrosis, and cubitus varus, there was no statistically significant difference between the two approaches. ConclusionThere was no clinically significant difference in elbow arc of motion and adverse events between the anterior approach and the posterior approach. Therefore, surgeons should choose the approach with which they are more familiar and comfortable.

Surgical outcome of locked facet in distractive flexion injury of the subaxial cervical spine: Single institution retrospective study.

The optimal surgical treatment for patients suffering from distractive flexion injury of the subaxial cervical spine with a locked facet (LF) is unknown. Closed reduction via an anterior or posterior approach is a treatment option for LF. We examined the surgical outcomes of patients treated for locked facet distractive flexion injury (LF-DFI) in this case series, with a particular emphasis on the surgical approach and reduction maneuver. We retrospectively analyzed the patients with distractive flexion injury of the subaxial cervical spine who underwent surgery at our hospital between November 2006 and April 2021. Patients who did not have facet subluxation or dislocation or those who achieved LF reduction prior to skin incision were excluded from this study. The patients were divided into 2 groups based on their initial approach, anterior or posterior approach. Perioperative clinical outcomes, including the American Spinal Cord Injury Association scale score, radiological changes, and complications were analyzed. This study enrolled 12 patients with LF-DFI. Four and 8 patients underwent the anterior and posterior approaches, respectively. The LF was reduced using an anterior approach with traction between the vertebral bodies in the anterior approach group and using a posterior approach with partial facetectomy in the posterior approach group. The preoperative American Spinal Cord Injury Association scale scores were as follows: A, 1 patient; B, 1 patient; C, 3 patients; D, 4 patients; and E, 3 patients. Nine patients showed no neurologic deterioration after surgery, whereas 2 had an aggravated neurologic status. Postoperatively, patients who underwent posterior open reduction did not exhibit worsened neurologic symptoms, whereas 2 patients who underwent the anterior approach showed worsened neurologic symptoms. At the final follow-up, all patients achieved radiological fusion, and no complications other than neurologic deterioration were identified. In terms of worsening postoperative neurologic status, a posterior approach using partial facetectomy for LF reduction is considered a safer surgical technique than an anterior approach. To avoid iatrogenic intraoperative cord injury, we recommend posterior approach in patients with LF-DFI.

Radiological outcome of operative treatment with posterior approach in patients with thoracolumbar junction traumatic injuries: A single-center pilot study in a developing country.

Background: The thoracolumbar junction (TLJ) represents a transition zone of the spine that leads to a high incidence of fractures. The treatment of burst fractures remains controversial regarding the ideal management. This study assessed the postoperative radiological outcome of TLJ fixation in patients with TLJ injuries who underwent surgery.Methods: All traumatic patients with TLJ injuries who were referred to the Khatam hospital of Zahedan between 2015 and 2020, with their thoracolumbar injury classification and severity score (TLICS) of four or more and who underwent surgery, were included in this study. The patients who entered the study were called for a follow-up examination. The degree of kyphosis, proximal junctional kyphosis, and fusion were assessed in these patients.Results: Among 273 patients, the average age was 43.5 ± 12.3 (21–73) years. One hundred and ninety-eight patients (72.5%) had no neurological symptoms at admission. Based on the above criteria, the kyphosis angle of these patients was calculated before surgery, which in 46 patients (16.8%), the kyphosis angle was more than 25°. Preoperation kyphosis was significantly associated with follow-up kyphosis (P < 0.001). Evidence of no fusion was also observed in 22 patients (8.1%). According to the Chi-square test, no association was observed between preoperative kyphosis and postoperative complications, including PJK and fusion (P > 0.05).Conclusion: According to our study, the posterior spinal fixation procedure is a low-complication method with an acceptable radiological outcome. Although kyphosis before surgery is a factor in developing long-term kyphosis, it is not associated with nonfusion and PJK.

Open vs Percutaneous Pedicle Instrumentation for Kyphosis Correction in Traumatic Thoracic and Thoracolumbar Spine Injuries.

Percutaneous pedicle instrumentation (PPI) has been used for the treatment of thoracic and thoracolumbar (TL) trauma. However, the ability of PPI to correct significant post-traumatic kyphosis requires further investigation. The objective of this study is to compare the amount of kyphosis correction achieved by PPI vs the traditional open posterior approach in patients presenting with significant kyphotic deformity following traumatic thoracic and TL spine injuries. Following Institutional Review Board approval, patients who underwent surgery for thoracic (T1-T9) or TL (T10-L2) fractures with at least 15° of focal kyphosis in a 5-year period were included in this study. Patients were separated into 2 cohorts based on surgical technique: traditional open posterior approach and minimally invasive PPI. Kyphosis correction was measured using Cobb angle 1 vertebrae above and 1 below the level of injury on sagittal preoperative computed tomography image, immediate and follow-up postoperative upright lateral radiographs. Initial degree of correction and loss of correction at the final follow-up were compared. Of 91 patients included, 65 (71%) underwent open surgery and 26 (29%) underwent PPI. Open patients had 11° (95% CI, 9°-13°) of immediate correction compared with 11° (95% CI, 6°-15°) for PPI (P = 0.81). Follow-up data were available for 70 patients with a median of 105.5 days. Both groups had 1° (95% CI, 0°-2°) of loss of correction at follow-up (P = 0.82). Regardless of surgical technique, obesity (>30 kg/m2) and AO type-A compression fractures had significantly less correction. For each unit of body mass index, there was a 0.75° decrease in correction achieved (P < 0.0001). Other factors did not influence the degree of correction. PPI techniques provide equivalent postoperative angular correction and maintenance of correction compared with open surgery in thoracic and TL trauma patients. This study provides evidence for spine surgeons to utilize either technique for treating significant traumatic kyphotic deformity. Therapeutic 3.

Three-column osteotomy by single-stage posterior approach in congenital and post-tubercular kyphosis: a comparison of outcomes.

To compare the clinical, radiological and functional outcomes of three-column osteotomy (3CO) by a single-stage posterior approach in patients with isolated congenital angular kyphosis (CK) and healed post-tubercular kyphosis (PTK). The hospital records of 30 patients with isolated congenital kyphosis (Group CK) and 51 patients with healed post-tubercular kyphosis (Group PTK), operated at a single centre utilizing a 3CO by a single-stage posterior-only approach, were retrospectively analysed. The two groups were compared with respect to selected demographic variables with clinical, radiological and functional outcome measures at a minimum follow-up of 24months. Patients in Group CK (median: 13years, range: 4-30years) presented earlier than those in Group PTK (median: 16years, range: 6-45years). The apex of the deformity was most often located in the thoracic spine in Group PTK, and in the thoracolumbar or lumbar spine in Group CK. The mean operative time (198.2 ± 31.5min v/s 174.4 ± 34.5; p = 0.01) and estimated blood loss (859.6 ± 312.2ml v/s 720.8 ± 187.3; p = 0.04) were significantly higher in Group PTK. While the local kyphosis angle was significantly corrected with surgery in both groups, the correction was significantly better in Group CK-this group also had significantly better overall functional (SRS-22r) scores at a follow-up of 24months (p < 0.05). The overall complication rate (29.4% v/s 23.3%) and neurological complication rate (9.8% v/s 6.6%) were higher in Group PTK. Permanent neurological deterioration occurred in one patient in each group. Patients with PTK have significantly higher age of presentation, higher operative time and higher complication rate as compared to CK. However, good functional outcomes and kyphosis angle correction can be achieved in both the groups with posterior-only three-column osteotomies.

Surgery for metastatic epidural spinal cord compression in thoracic spine, anterior or posterior approach?

BackgroundThe most commonly encountered tumour of the spine is metastasis, and thoracic spine is the most commonly metastatic spine. Controversy exists regarding the optimal surgical approach for this kind of patient. The author conducted a study to assess the differences between anterior thoracotomy and a posterior approach in patients with malignant epidural cord compression in the thoracic spine. MethodsBetween January 2004 and December 2017, 97 patients with metastatic thoracic lesion were stratified into two groups by approach method to the lesion site: Group A - mean anterior thoracotomy, decompression and fixation; and Group P - represented posterior decompression and fixation. Survival time, neurologic status, each complication by surgery or in hospital, and days in intensive care unit(ICU) were compared. ResultsTwenty-five patients were grouped in Group A, and 72 patients belonged to Group P. Lung cancer was the most common primary cancer in both groups. Operation time (213.0 vs. 199.2 min, p = 0.380) and blood loss (912.5 vs. 834.4 ml, p = 0.571) were not statistically significantly different between the two groups. Six patients in Group A (24%) and 6 in Group P (8.3%) developed complications (p = 0.040). Patients in Group A required more days of care in ICUs (2.36 vs. 0.19 days, p < 0.001). The longer survival was seen in Group P (15.4 vs. 11.2 months) but with no significant difference. ConclusionA lower surgical complication rate and fewer days of care in ICU were seen in Group P. The authors would prefer a posterior approach for those with thoracic metastatic tumour.

Fewer Hip Dislocations With Anterior Total Hip Arthroplasty for Displaced Femoral Neck Fracture.

The primary goal of this study was to compare dislocation rates with an anterior approach vs a posterior approach for patients who underwent total hip arthroplasty (THA) for displaced femoral neck fracture. A retrospective review was conducted of patients who underwent THA for acute femoral neck fracture at the authors' level I trauma center. All patients had at least 1 year of follow-up. Modified Harris Hip Score (mHHS) and EuroQol 5D-5L score were obtained to assess hip function and overall quality of life at a minimum of 12 months postoperatively. The study population included 76 patients (posterior, 22; anterior, 54), with mean follow-up of 39 months (range, 12-125 months). Significantly more postoperative complications occurred in the posterior group compared with the anterior group (7 vs 4, respectively; P=.006). In addition, significantly more hip dislocations occurred in the posterior group compared with the anterior group (3 vs 1, respectively; P=.037). The study did not show a difference in mHHS (anterior, 82; posterior, 77; P=.411). The findings suggest that an anterior-based approach to THA may result in fewer complications than a posterior-based approach for patients who have displaced femoral neck fracture. Patients should be counseled on the higher perioperative risk after surgery compared with patients undergoing elective THA. Patients undergoing THA with an anterior approach for femoral neck fracture can expect to achieve good hip functional outcome and good quality of life 12 months after surgery. [Orthopedics. 2021;44(2):e248-e252.].

Posterior cervical sequestrectomy via keyhole foraminotomy: a case series comparing microdiscectomy with endoscope assisted discectomy

To report the clinical outcomes of microdiscectomy (MD) and endoscope assisted discectomy (EAD) techniques via the posterior approach in patients with cervical disc herniations (CDHs). The data were obtained from retrospective review of the patient?s charts and the latest follow-up examination. A total of 83 cases with CDH who were treated by posterior cervical discectomy (PCD), between 2010 and 2019, were reviewed. MD was used in 42 patients (male: 20, female: 22) with a mean age of 51.1 years. In MD group, all patients had pain, and 26 of them had additional weakness. Visual analogue scale (VAS) neck score was 7.72, VAS arm score was 8.83; PROLO score was 7.41. EAD was used in 41 patients (male: 26, female: 15) with a mean age of 38.7 years. In EAD group, all patients had pain, and 20 of them had additional weakness. VAS neck and arm scores were 7.75, and 8.72, respectively; PROLO score was 7.44. Mean follow-up time was 24.7 months. The scores at the latest exam are as follows: in MD group, VAS score for neck was 2.32, for arm 1.11; PROLO score was 9.58; in EAD group, VAS score for neck was 2.18 and for arm 0.97; PROLO score was 9.66. Both surgical techniques were success with statically significance (p?0.05) according to the scores.The techniques were equally effective while postoperative VAS (p > 0.412) and PROLO (p > 0.980) scores were similar in both groups. Both approaches are effective for selected patients with soft cervical disc herniation in which settled lateral location. Both techniques allow working with two handle, therefore facilitating the gentle manipulation that can obtain for avoiding hazardous effect to spinal cord and nerve root.

Analysis of effectiveness of greater trochanteric osteotomy approach and K-L posterior approach in patients with type Ⅳ Pipkin fracture

To investigate the effectiveness of two surgical approaches in the treatment of type Ⅳ Pipkin fracture. The clinical data of 15 patients with type Ⅳ Pipkin fracture treated surgically between July 2013 and June 2018 were retrospectively analyzed. According to different surgical approaches, they were divided into group A (8 cases, using K-L posterior approach) and group B (7 cases, using greater trochanter osteotomy approach). There was no significant difference in gender, age, cause of injury, and interval from injury to operation between the two groups ( P>0.05). The incision length, operation time, intraoperative blood loss, hospital stay, fracture healing time, and complications of the two groups were recorded. Hip joint function recovery was evaluated according to Thompson-Epstein functional evaluation system. All the 15 patients were followed up 1-5 years, with an average of 2.5 years. There was no significant difference in operation time between the two groups ( t=14.681, P=0.100); the incision length, intraoperative blood loss, and fracture healing time in group A were all greater than those in group B, and the hospital stay was shorter than that in group B, showing significant differences ( P<0.05). In group A, 1 patient presented hip pain, clasthenia, and limited mobility after operation, 1 patient presented ossifying myositis, 1 patient presented osteonecrosis of the femoral head, 1 patient presented fat liquefaction of incision, and 1 patient presented sciatica, with a complication incidence of 62.5%. Postoperative hip pain occurred in 1 patient and ossifying myositis in 2 patients in group B, with a complication incidence of 42.9%. There was no significant difference in the incidence of complications between the two groups ( χ 2=-0.735, P=0.462). At last follow-up, according to Thompson-Epstein functional evaluation system, the results in group A were excellent in 3 cases, good in 2 cases, fair in 2 cases, and poor in 1 case, with an excellent and good rate of 62.5%; in group B, the results were excellent in 4 cases, good in 2 cases, and fair in 1 case, and the excellent and good rate was 85.7%. There was no significant difference in good and fair rate between the two groups ( χ 2=-0.990, P=0.322). K-L posterior approach is more convenient in the fracture treatment during operation, but it has greater trauma, greater vascular damage, and more blood loss. The greater trochanter osteotomy approach can better protect the blood supply of femoral head, shorten the operation time, reduce intraoperative blood loss, and reduce postoperative complications. It is an ideal way in the surgical treatment of type Ⅳ Pipkin fracture.

Pain relief and good functional outcomes after hip endoscopy via posterior approach in patients with ischiofemoral impingement.

Ischiofemoral impingement is considered to be an uncommon and difficult pathology to diagnose with respect to hip pain etiology. The objective was to describe the clinical results of endoscopic lesser trochanter resection via a posterior approach in patients with Ischiofemoral impingement. This was a retrospective observational study of consecutive patients with Ischiofemoral impingement, who underwent endoscopic resection of the lesser trochanter via a posterior approach, between 2015 and 2018. Clinical results were evaluated using the ischiofemoral impingement test, long-stride walking test, modified Harris Hip Score (mHHS) and the Oxford scale to assess the strength of the iliopsoas muscle as well as the presence of complications. Preoperative and postoperative ischiofemoral space was measured to assess whether the resection of the lesser trochanter was adequate. 16 hips in 13 patients (mean age: 34.4 ± 12.1years, 11 women) with a follow-up period between 24 and 59months were included. Preoperative ischiofemoral space ranged from 6.4 to 22.4mm, a measure > 17.0mm was achieved in 15 hips without the presence of pain in IFI test and long-strides walking test. Function improved postoperatively, as reflected by a higher mean mHHS (preoperative: 44.6 ± 21.5, postoperative: 81.2 ± 15.1, p < 0.05). After surgery, the strength of the iliopsoas muscle was not decreased compared to the preoperative measure. Three complications were reported, including two cases that required revision surgery. Endoscopic resection of the lesser trochanter via posterior approach provides satisfactory outcomes with symptom relief and good functional results in patients with Ischiofemoral impingement. It is important to discuss the benefits and risks when offering this treatment choice. Level IV.

Surgical outcome of high grade spondylolisthesis following reduction, instrumentation, fusion through single stage posterior approach

Introduction: Literature evidence of outcome of reduction, spinal fusion through single stage posterior approach in patients of high-grade spondylolisthesis is lacking. Aim of the study, is to study the surgical outcome of High-grade spondylolisthesis patients, managed through single stage posterior approach. Materials and Methods: We have retrospectively analysed high -grade spondylolisthesis adolescents and young adults of patients of age less than 30 years, who have undergone reduction and spinal fusion in our institute for the past 5 years with a follow-up of two years. 27 patients, who have undergone surgery in the time period between 2011 to 2016, were evaluated with preop standing lumbosacral radiograph for slip angle, L5 incidence angle, lumbar lordosis, slip percentage. Oswestry disability index [ODI] score for low back pain, neurological examination, sf-36 health survey questionnaire are the clinical parameters analysed. The patients who had undergone the surgery were followed up for 2 years and evaluated with standing radiographs for all the above radiological parameters, clinical parameters and assessment of spinal fusion by Bridwell criteria. Parameters were analysed statistically with SPSS software version 25.0. p less than 0.05 was considered statistically significant. Results: The aim of the surgery is to reduce the L5-S1slip angle to less than 30 degrees, and not about the complete restoration of displacement of L5 over S1. Mean slip angle, L5 incidence angle, Lumbar lordosis, slip percentage changed from 41.57 to12.10 [p

PD-1102: A Phase 1 study of VY-AADC01 Administered Using a Posterior Approach in Patients with Parkinson’s Disease and Motor Fluctuations (P1.8-017)

PD-1102: A Phase 1 study of VY-AADC01 Administered Using a Posterior Approach in Patients with Parkinson’s Disease and Motor Fluctuations (P1.8-017)

Surgical treatment of cervical subaxial intraspinal extradural cysts using a full-endoscopic uniportal posterior approach

Symptomatic intraspinal extradural cysts of the cervical subaxial spine are rare, but usually require surgery. Conventional posterior decompression is the gold standard. However, there is increasing experience with endoscopic surgical techniques. The purpose of the study is to evaluate the technical implementation and outcomes of a full-endoscopic uniportal technique via the posterior approach in patients with symptomatic intraspinal extradural cysts of the cervical subaxial spine. Seven consecutive patients with a subaxial location of symptomatic intraspinal extradural cysts were decompressed in a full-endoscopic uniportal technique via the posterior approach between 2009 and 2015. Imaging and clinical data were collected in follow-up examinations for 18 months. In all cases, the cyst was completely removed and adequate decompression was achieved using the full-endoscopic uniportal technique. One patient developed a dural leak that was sutured and covered intraoperatively. No other complications requiring treatment were observed. All patients had a good clinical outcome with stable regression of the radicular and central nerve pain or neurological deficits. The imaging follow-up showed sufficient decompression in all cases. No evidence was found of increasing instability during the follow-up period. The full-endoscopic uniportal operation with a posterior approach allows the resection of the cyst and can minimize trauma and destabilization and has technical benefits and a low complication rate. It is an alternative surgical method that can offer advantages and is considered by the authors to be the surgical technique of choice for cervical subaxial intraspinal extradural cysts.

Clinical effect of clivo-axial angle in posterior approach for patients with unstable upper cervical spine

Objective To investigate the clinical effect of clivo-axial angle(CAA)in the posterior approach for patients with unstable upper cervical spine. Methods Twenty-one patients with unstable upper cervical spine treated with posterior approach surgery from October 2014 to March 2016 were included in this study, and the patients were divided into the decompression group (11 cases) and the non-decompression group (10 cases) according to whether the intraoperative decompression was included.The clivo-axial angle(CAA) were measured by mobile three-dimensional before and after the surgery in order to estimate the reduction of spinal cord compression effect after the posterior cervical surgery combined with the reduction, fixation and bone graft fusion, then to guide the restoration.CT was used to measure the CAA and MR was used to measure the cervico-medullary angle (CMA) before operation and 3 months after operation.Japanese Orthopedic Association (JOA) scores was used to evaluate the neurological function 6 months after operation. Results All patients were followed up for 6-12 months.CMA ((156.3±3.6°) vs.(155.9±2.7°)) and CAA ( (154.3±5.1°) vs.(151.3±4.7°)) of the decompression group and the non-decompression group at 3 months after surgery were improved significantly compared with those collected before the surgery (CMA: (131.5±0.6°) vs.(131.1±0.5°); CAA: (133.2±1.7°) vs.(132.4±1.2°)), the differences were statistically significant (CMA: t=-21.81, P=0.00 vs.t=-28.54, P=0.00; CAA: t=-12.44, P=0.00 vs.t=-11.68, P=0.00). After operation, CAA ((152.3±1.3) vs.(132.6±1.5)) was significantly improved, compared with that before reduction ((131.1±1.9) vs.(132.4±1.5°)) (t=-30.09, P=0.00 vs.t=-35.93, P=0.00). JOA scores of the two groups at 6 months after operation ((9.8±1.3) points vs.(10.3±1.7) points) were significantly lower than those before the surgery ((7.1±0.7) points vs.(7.6±1.1) points), the differences were statistically significant (t=6.01, P=0.00 vs.t=4.36, P=0.00). No complications such as fixed failure, infection, spinal cord injury and vertebral artery injury were found in all patients. Conclusion For patients with upper cervical spine instability, the usage of intraoperative three-dimensional C arm scanning in CAA measurement to determine the effect of spinal cord compression can guide the reduction, simple and feasible, the clinical effect is satisfactory. Key words: Upper Cervical Spine; Instability; Clivo-axial Angle

A radical procedure of circumferential spinal cord decompression through a modified posterior approach for thoracic myelopathy caused by severely impinging anterior ossification

Background contextThoracic myelopathy caused by an anterior, massive ossified plaque is often progressive and responds poorly to conservative treatment. Direct removal of the compressing ossification is the optimal procedure for a spinal cord that is severely impinged anteriorly. However, both anterior and posterior decompressive manipulations have caused catastrophic iatrogenic spinal cord injuries. A comprehensive treatment method for severe thoracic myelopathy that enables a sufficient and safe decompression of the spinal cord is needed. PurposeThe purpose of this study is to demonstrate the efficacy, safety, and results of a one-stage circumferential decompressive procedure using a modified posterior approach in patients with severe thoracic myelopathy resulting from anterior spinal compression. Study designA modified procedure of circumferential spinal cord decompression for thoracic myelopathy is described. A retrospective study was conducted to investigate the clinical outcomes of 23 sequentially treated patients. Patient sampleTwenty-three patients were treated sequentially with a modified procedure for circumferential spinal cord decompression for thoracic myelopathy. Outcome measuresOutcomes were assessed using the Japanese Orthopedic Association (JOA) score, modified Frankel classification, Hirabayashi recovery rate, and a general assessment of complications. MethodsTwenty-three patients with thoracic myelopathy caused by a massive, anterior ossified structure were treated with an extensive posterior laminectomy, anterior removal of the ossification, and interbody fusion with kyphosis-reversing stabilization through a modified posterolateral approach. The neurologic outcomes are evaluated according to the JOA and the modified Frankel classification before surgery, 2 weeks after surgery, 1 year after surgery, and at the final follow-up visit. The surgical outcomes are also described using the Hirabayashi recovery rate. Radiographs, computed tomography (CT), and magnetic resonance imaging were performed before and after surgery. A postoperative CT scan was obtained to determine the efficacy of the decompression. Operative time, intraoperative blood loss, and complications were reviewed from the medical records. In addition, a 48-year-old man who presented with severe thoracic myelopathy resulting from anterior impingement with multiple osteophytes is described as an illustrative patient. ResultsThe sites of ossification in this series were distributed widely, from T4–T12. The anterior ossified plaques of all patients were resected completely. Five patients who had intraoperative evidence of dural ossification required resection of the ossified dura matter. The average operating time was 276 minutes. Mean intraoperative blood loss was 1,350 mL. The postoperative follow-up ranged from 2.5 to 6 years, with an average of 4.6 years. The average preoperative JOA score was 4.3±1.5 points, and it improved to 6.1±1.9 points 2 weeks postoperatively, to 8.1±1.8 points 1 year postoperatively, and to 8.5±1.9 points at the most recent follow-up. The overall Hirabayashi recovery rate at the final examination averaged 63.6±22.4%. Eight patients were graded as excellent, 10 as good, 4 as fair, and 1 as unchanged. No patient was graded as deteriorated. The paralysis improved by at least 1 grade in 22 patients (95.7%). Transient deterioration of thoracic myelopathy occurred immediately after surgery in three patients (13%). Cerebrospinal fluid leakage occurred in six patients (26.1%). One patient sustained severe bilateral groin pain, three had unilateral intercostal neuralgia, and pleura tear occurred in one patient. ConclusionOne-stage posterior decompression, anterior extirpation of the ossification, and interbody fusion with instrumentation via a modified posterior approach is a safe and effective treatment for severe thoracic myelopathy resulting from prominent anterior impingement. This procedure is technically demanding, and the indications are limited to thoracic myelopathy caused by severe anterior impingement of various etiologies from T4–T12.

Anterior Versus Posterior Approach for Treatment of Cervical Spondylotic Myelopathy

Systematic review. We performed a systematic review to determine the comparative effectiveness and safety profiles of anterior versus posterior decompression procedures for multilevel cervical spondylotic myelopathy (CSM). CSM is a common cause of neurological dysfunction. It is well established that surgical decompression of the cervical spinal cord is an effective treatment option for CSM. Because of the lack of well-designed prospective studies, there remains a lack of consensus whether multilevel spondylotic compression is best treated via an anterior or posterior surgical route and whether one of these surgical approaches is superior in terms of patient outcomes and/or complication profiles. We conducted a systematic search for literature published through September 2012. We sought to identify comparative studies (e.g., randomized controlled trials, cohort studies) comparing anterior with posterior procedures in patients with 2-level or greater cord compression resulting in CSM. Standardized mean differences were calculated to allow comparisons of the change (i.e., improvement or decline) in scores between anterior and posterior surgical procedures by study. Clinical recommendations were made through a modified Delphi approach by applying the GRADE (Grading of Recommendation Assessment, Development and Evaluation)/AHRQ (Agency for Healthcare Research and Quality) criteria. We identified 8 level III retrospective cohort studies that met the inclusion criteria from a total of 135 possible studies for review. With regard to effectiveness between the 2 approaches, improvements in JOA (Japanese Orthopaedic Association) scores were similar, whereas canal diameter change was larger after posterior surgery. With regard to safety, postoperative C5 palsy rates were similar, infection rates were lower with anterior surgery, and dysphagia rates were lower with posterior surgery. This systematic review demonstrates that, for both effectiveness and safety, there is no clear advantage to either an anterior surgical approach or a posterior surgical approach when treating patients with multilevel CSM. With that, a surgical strategy developed on a patient-to-patient basis should be used to achieve optimal patient outcomes. In addition, development of a consensus for standardized reporting of outcome measures and complication profiles would facilitate improved comparisons across differing treatment centers and surgical techniques. EVIDENCE-BASED CLINICAL RECOMMENDATIONS: We recommend an individualized approach when treating patients with CSM accounting for pathoanatomical variations (ventral vs. dorsal, focal vs. diffuse, sagittal, dynamic instability) because there are similar outcomes between the anterior and posterior approaches with regard to effectiveness and safety. Low. Strong.