Postoperative Japanese Orthopaedic Association Scores Research Articles

Analysis between preoperative cervical radiographic parameters represented by the K-line tilt and the short-term prognosis of laminoplasty for posterior longitudinal ligament ossification: A retrospective study.

ObjectivesTo investigate the relationship between preoperative radiographic parameters and the short-term prognosis of patients with cervical ossification of the posterior longitudinal ligament (OPLL) who underwent laminoplasty (LAMP).MethodsA retrospective analysis of Cervical OPLL 50 patients with K-line (+) OPLL with no cervical kyphosis who received LAMP was performed. Based on preoperative neutral position x-ray, the K-line tilt, C2–C7 SVA (sagittal vertical axis), CL (cervical lordosis), T1 slope, and T1 slope-CL were recorded. The JOA (Japanese orthopaedic association scores) score and the cervical kyphosis change were recorded 1 year after surgery. Patients were divided into good and poor prognosis groups according to the median (12.5) of the postoperative JOA score.ResultsThere were differences between the two groups in K-line tilt, C2–C7 SVA, and T1 slope (all ps < 0.05). There was a strong linear correlation between the three, K-Line tilt, JOA score, and C2–C7 SVA. The degree of influence of K-line tilt, C2–C7 SVA, T1 slope on postoperative JOA score was analyzed using multiple linear regression, and the absolute value of the standardized coefficient Beta were 0.550, 0.319, 0.185, respectively. There was no cervical kyphosis change 1 year after surgery.ConclusionAs preoperative cervical parameters, the influence of K-line tilt, C2–C7 SVA, and T1 slope on postoperative JOA score decreases in order. There was a linear relationship between preoperative K-line tilt and postoperative JOA score, implying that patients with cervical OPLL with high K-line tilt were not eligible for LAMP. K-line tilt was not predictive of cervical kyphosis change after LAMP in patients with OPLL at short-term follow-up.

Comparison of the Safety and Efficacy of Three-Dimensional Guiding Templates and Free Hand Technique for Cervical Pedicle Screw Fixation: A Retrospective Study

Aim. To compare the safety and efficacy of computed tomography (CT)-assisted three-dimensional guiding templates (3DGTs) and free-hand (FH) technique for posterior cervical pedicle screw fixation in cervical spondylotic myelopathy (CSM) treatment. Methods. Thirty-five patients (216 screws) with CSM and developmental cervical stenosis were randomly divided into groups A (FH) and B (3DGTs). All patients underwent modified posterior surgery with cervical pedicle screw insertion (C1-7). Preoperative, postoperative, and intergroup comparisons of efficacy were evaluated using the visual analog scale (VAS), Japanese Orthopaedic Association (JOA), and Short Form 12 (SF-12) scores and JOA score improvement rate. Incidence of intra- and postoperative complications was analyzed. Postoperative cervical spine CT was performed to evaluate (i) the pedicle screws' deviation angle from the optimal path (sagittal deviation, α; coronal deviation angle, β), screw insertion point's deviation distance (d), and screw accuracy and (ii) the deviation angle and distance of screw entrance point of pedicle screws from the optimal channel. Results. All patients successfully completed the procedures. Groups A and B did not significantly differ in age, sex ratio, body mass index, operative time, or intraoperative blood loss amount. Postoperative VAS, JOA, and SF-12 scores improved in both groups. VAS, JOA, or SF-12 scores did not significantly differ between the 2 groups. The α, β, and d scores were lower in group B, but accuracy was higher in group B. Conclusions. 3DGTs and FH technique show comparable outcomes with respect to neurological improvement and safety.

Far-Lateral Cervical Approach as a Minimally Invasive Technique for Excision of Upper Cervical Anterolateral and Anterior Meningiomas and Dumbbell Schwannomas: Technical Report and Case Series

Objective: To demonstrate the surgical details of the far-lateral approach (FLA) as a minimally invasive technique for the excision of the upper cervical anterolateral and anterior meningiomas and dumbbell schwannomas, and to assess the clinical and radiological outcomes in patients who underwent surgery.Methods: In this technical report and case series we demonstrated the FLA technique and reported patients who underwent the FLA for C1-C4 anterolateral and anterior meningiomas and dumbbell schwannomas between June 2007 and June 2020. All patients’ relative preoperative demographic, clinical, radiographic, operative, histopathological, and perioperative complications and follow-up clinical and radiographic data were reported.Results: A total of 19 patients including 12 females and 7 males with a mean age 56.7±17.6 years and mean duration of symptoms 12.8±12.3 months were reported. Nine patients with anterolateral meningiomas, five with anterior meningiomas, and 5 with dumbbell schwannomas underwent uneventful FLA procedures. Gross total resection (GTR) of tumors was reported in 17 patients (89.5%). Preoperative Japanese Orthopedic Association (JOA) score was normal in ten, grade-I in five, and grade-II in 4 patients, while at the last follow-up it improved to normal in seventeen and grade-I in two patients. Reported postoperative JOA scores at 6 months and at the last follow-up showed that all patients improved at least one grade on JOA scores. There was cerebrospinal fluid (CSF) leak into the suction drain in three patients and superficial wound infection in another one.Conclusion: Our results advocate the use of the far-lateral cervical approach as a minimally invasive technique in the resection of the upper cervical anterolateral and anterior meningiomas and dumbbell schwannomas as a safe and effective technique.

Analysis of treatment effect with teriparatide on device-related vertebral osteopenia after lumbar spinal interbody fusion using Hounsfield unit values: A retrospective cohort study.

The aim of the present study was to investigate the effect of teriparatide on device-related vertebral osteopenia after single lumbar spinal interbody fusion and compare osteopenia in fused and nonfused spinal segments using Hounsfield unit (HU) values. The present study was a retrospective cohort study. We reviewed 68 consecutive patients (28 men and 40 women) who underwent single-segment (L4-5) transforaminal lumbar interbody fusion with cage and pedicle screw fixation. The patients were divided into 2 groups according to whether they were treated with teriparatide (teriparatide and nonmedication groups). The primary outcome measure was HU values measured on computed tomography images from each L1 to S1 vertebral body12-month postoperatively. Secondary outcome measures were femoral neck bone mineral density (BMD), T-score, osseous union, and clinical outcomes using the Japanese Orthopedic Association scoring system 12-month postoperatively. There were significant decreases in HU values of lumbar vertebral bodies at all levels and BMD and T-score values obtained using dual-energy X-ray absorptiometry of the femur between preoperative and postoperative 12-month computed tomography in the nonmedication group (P < .05). On the other hand, there were no significant differences between properative and postoperative 12-month HU values of each lumbar vertebral body and BMD values of the femur in the teriparatide group. Osseous fusion scores in the teriparatide group were significantly better than those in the nonmedication group. There were no significant differences in postoperative Japanese Orthopedic Association scores between the 2 groups. Administration of teriparatide during the perioperative period may prevent bone loss associated with spinal fusion surgery.

Instrumented fusion versus instrumented non-fusion following expansive open-door laminoplasty for multilevel cervical ossification of the posterior longitudinal ligament.

To compare the outcomes of expansive open-door laminoplasty with instrumented fusion (ELIF) and expansive open-door laminoplasty with instrumented non-fusion (ELINF) for multilevel cervical ossification of the posterior longitudinal ligament (OPLL). Patients who underwent ELIF or ELINF due to multilevel cervical OPLL from June 2013 to June 2019 were identified. Clinical and radiological outcomes were compared between the two groups. A total of 78 patients were enrolled in this study with a minimum follow-up of 24months, including 42 patients in the ELIF group and 36 patients in the ELINF group. At the final follow-up, sagittal vertical axis (SVA) and C2-C7 Cobb angle in the ELIF group were significantly better than those in the ELINF group, and cervical range of movement (ROM) in the ELIF group decreased significantly than that in the ELINF group. The incidence of OPLL progression at the final follow-up was 4.76% (2/42) in the ELIF group and 27.78% (10/36) in the ELINF group. Postoperative Japanese Orthopaedic Association (JOA) score, neck disability index (NDI), and visual analog scale (VAS) score improved significantly in each group, but JOA score and recovery rate (RR) in the ELIF group were significantly better than those in the ELINF group at the final follow-up. When K-line was positive, the difference in the final JOA score between the two groups was not significant, but the RR in the ELIF group was significantly better than that in the ELINF group. When K-line was negative, the final JOA score and RR in the ELIF group were significant higher than those in the ELINF group. ELIF and ELINF were two effective surgical procedures for treating multilevel cervical OPLL. However, ELIF was superior to ELINF due to better postoperative JOA score and RR, significant improvement of C2-C7 Cobb angle and maintenance of SVA, and suppressant effect on OPLL progression, especially for patients with K-line (-) OPLL.

Phase I 270° single-incision percutaneous spinal endoscopy for decompression treatment of thoracic spinal stenosis

This study aimed to explore the feasibility of Phase I percutaneous spinal endoscopy with a 270° single incision in the ventral and dorsal dura mater for decompression treatment of thoracic spinal stenosis (TSS). Phase I percutaneous spinal endoscopy with a two-path (posterior and posterolateral approaches) single incision with a 270° decompression was performed in four cases of TSS with compression in the ventral and dorsal dura mater. The affected intervertebral space was located during the surgery, and the ossified ligamentum flavum in the ventral and dorsal dura mater was removed via laminectomy, which formed a decompression space in the thoracic cord. Next, posterolateral transforaminal expansion and plasty were performed to remove the ventral intervertebral disk. The visual analogue scale (VAS) score, thoracic spinal cord function score of the Japanese Orthopaedic Association (JOA) (11-point method), and Oswestry Disability Index (ODI) scores were used to evaluate the clinical efficacy. No dura mater or thoracic nerve injury occurred during the surgery. The symptoms of weakness in the lower extremities improved after the surgery. The postoperative magnetic resonance imaging and computed tomography examinations showed compression removal and dura mater bulging. The postoperative VAS, JOA, and ODI scores improved compared with the preoperative scores. Two surgical trajectories, posterior and posterolateral approaches, were established by a single incision using thoracic spinal canal decompression with Phase I 270° single-incision percutaneous spinal endoscopy. The posterior approach was performed mainly by translaminar unilateral fenestration and bilateral decompression in the ventral and dorsal dura mater, whereas the posterolateral approach was performed by decompression in the ventral dura mater to the midline of the vertebrae. This surgical method could be applied as a safe and feasible minimally invasive treatment for TSS with compression on both the ventral and dorsal dura mater.

Postoperative progression of ligamentum flavum ossification after posterior instrumented surgery for thoracic posterior longitudinal ligament ossification: long-term outcomes during a minimum 10-year follow-up.

The authors sought to investigate clinical and radiological outcomes after thoracic posterior fusion surgery during a minimum of 10 years of follow-up, including postoperative progression of ossification, in patients with thoracic ossification of the posterior longitudinal ligament (T-OPLL). The study participants were 34 consecutive patients (15 men, 19 women) with an average age at surgery of 53.6 years (range 36-80 years) who underwent posterior decompression and fusion surgery with instrumentation at the authors' hospital. The minimum follow-up period was 10 years. Estimated blood loss, operative time, pre- and postoperative Japanese Orthopaedic Association (JOA) scores, and JOA score recovery rates were investigated. Dekyphotic changes were evaluated on plain radiographs of thoracic kyphotic angles and fusion levels pre- and postoperatively and 10 years after surgery. The distal junctional angle (DJA) was measured preoperatively and at 10 years after surgery to evaluate distal junctional kyphosis (DJK). Ossification progression at distal intervertebrae was investigated on CT. The Cobb angles at T1-12 were 46.8°, 38.7°, and 42.6°, and those at the fusion level were 39.6°, 31.1°, and 34.1° pre- and postoperatively and at 10 years after surgery, respectively. The changes in the kyphotic angles from pre- to postoperatively and to 10 years after surgery were 8.0° and 7.2° at T1-12 and 8.4° and 7.9° at the fusion level, respectively. The DJA changed from 4.5° postoperatively to 10.9° at 10 years after surgery. There were 11 patients (32.3%) with DJK during follow-up, including 4 (11.8%) with vertebral compression fractures at lower instrumented vertebrae or adjacent vertebrae. Progression of ossification of the ligamentum flavum (OLF) on the caudal side occurred in 8 cases (23.6%), but none had ossification of the posterior longitudinal ligament (OPLL) progression. Cases with OLF progression had a significantly lower rate of DJK (0% vs 38.5%, p < 0.01), a lower DJA (3.4° vs 13.2°, p < 0.01), and a smaller change in DJA at 10 years after surgery (0.8° vs 8.1°, p < 0.01). Posterior decompression and fusion surgery with instrumentation for T-OPLL was found to be a relatively safe and stable surgical procedure based on the long-term outcomes. Progression of OLF on the caudal side occurred in 23.6% of cases, but cases with OLF progression did not have DJK. Progression of DJK shifts the load in the spinal canal forward and the load on the ligamentum flavum is decreased. This may explain the lack of ossification in cases with DJK.

The Deterioration of Cervical Kyphosis During Neck Flexion after Laminoplasty Affects the Surgical Outcome of Cervical Spondylotic Myelopathy.

A retrospective single-center study. The present study investigated whether postoperative cervical alignment changes, in addition to preoperative patient backgrounds, imaging parameters, and disease severity, affect outcomes 1 year after laminoplasty. One hundred and three cervical spondylotic myelopathy (CSM) patients who underwent laminoplasty were enrolled. Preoperative and postoperative (1-year) Japanese Orthopedic Association (JOA) scores, cervical alignment, and balance on X-rays were assessed. Patients were classified into 2 groups for a univariate analysis according to the status of the recovery rate (RR) of the JOA score ≥50%. A multiple logistic regression analysis was performed to identify factors associated with good surgical outcomes a. The mean RR of the JOA score was 47.5% and the loss of cervical lordosis in the neutral position was 5.5°. The univariate analysis revealed slight differences in age, sex, and the duration of disease. Preoperative C2-7 angles were not significantly different. The C2-7 angle during flexion after surgery was significantly smaller in Group F. In the multiple logistic regression analysis, significant factors associated with the status of RR≥50% were a younger age (OR: .75, 95%CI: .59-.96), shorter duration of disease (OR: .94, 95%CI: .89-.99), and a lordotic C2-7 angle during neck flexion after surgery (OR: 1.47, 95%CI: 1.1-1.95). We retrospectively assessed the surgical outcomes of laminoplasty in 103 CSM cases. In addition to an older age and longer duration of disease, postoperative deteriorations in cervical kyphosis during neck flexion had a negative impact on outcomes.

Substantially High Hidden Blood Loss in Oblique Lateral Interbody Fusion: Retrospective Case Series.

Background and Objectives: Measured blood loss frequently underestimates true blood loss; this discrepancy is called hidden blood loss (HBL). The purpose of the present study was to measure HBL in oblique lateral interbody fusion (OLIF). Materials and Methods: Patients who underwent two-stage OLIF at our institute from September 2017 to September 2021 were retrospectively reviewed. Total blood loss (TBL) and HBL were calculated using the gross formula. The age, sex, body mass index (BMI), operation time, measured blood loss, the number of fused segments, hematocrit (HCT), anticoagulant or platelet medication, blood transfusion, days of hospitalization, pre-/postoperative Japanese Orthopedic Association (JOA) score, and JOA recovery rate were compared. Results: A total of thirteen patients were included in the study. The average age, BMI, number of fused segments, operation time, estimated blood loss, and blood transfusion were 69.5 years, 23.3, 2.5, 250 min, 122 mL, and 230 mL, respectively. Five patients received anticoagulant or platelet therapy. Days of hospitalization, pre-/postoperative JOA score, and JOA recovery rate were 14.9 ± 5.1, 19.9 ± 2.7, and 18.0 ± 43.4%, respectively. The TBL and HBL were 688 and 797 mL, respectively. Stepwise multiple regression analysis revealed that younger age (p = 0.01), female sex (p = 0.01), and number of fused segments (p = 0.02) were significantly associated with higher HBL. Conclusions: The HBL in OLIF was 797 mL, which was more than other previously reported procedures. Therefore, OLIF may not be less invasive in terms of HBL. Blood loss after surgery should be considered, especially when patients are younger, are female, and have a greater number of fused segments.

Comparison of nano-hydroxyapatite/polyamide 66 bioactive support and autologous iliac bone in bone grafting and fusion for elderly patients with lumbar tuberculosis

To investigate the safety of nano-hydroxyapatite/polyamide 66 (n-HA/PA66) bioactive support in bone grafting and fusion for elderly patients with lumbar tuberculosis, and to analyze its effectiveness and advantages by comparing with autologous iliac bone grafting. A retrospective analysis was performed on 48 elderly patients with lumbar tuberculosis who met the selection criteria between January 2017 and January 2020. The patients all underwent one-stage posterior pedicle screw internal fixation combined with anterior lesion removal and bone grafting and fusion, of which 23 cases applied n-HA/PA66 bioactive support+allogeneic bone graft (n-HA/PA66 group) and 25 cases applied autologous iliac bone graft (autologous iliac bone group). There was no significant difference between the two groups in gender, age, bone density, disease duration, lesion segment, and preoperative pain visual analogue scale (VAS) score, Japanese Orthopaedic Association (JOA) score, and Cobb angle ( P>0.05). The operation time, intraoperative blood loss, and postoperative complications, as well as the VAS score, JOA score, American Spinal Injury Association (ASIA) spinal cord injury grading, Cobb angle, and bone fusion were recorded and compared between the two groups. The operations were completed successfully in both groups. n-HA/PA66 group had significantly less operation time and intraoperative blood loss than the autologous iliac bone group ( P<0.05). All patients were followed up 12-24 months, with an average of 15.7 months. And the difference in follow-up time between the two groups was not significant ( P>0.05). Postoperative complications occurred in 3 cases (13%) in the n-HA/PA66 group and 10 cases (40%) in the autologous iliac group, and the difference in the incidence of complications between the two groups was significant ( χ 2=4.408, P=0.036). The postoperative VAS scores and JOA scores significantly improved when compared with the preoperative scores in both groups ( P<0.05), and the difference was significant ( P<0.05) between 2 weeks after operation and the last follow-up. The difference in VAS score at 2 weeks after operation was significant between the two groups ( P<0.05), and there was no significant difference ( P>0.05) at the other time points. At last follow-up, according to the ASIA grading, the effective improvement rate was 86% (18/21) in the n-HA/PA66 group and 90% (18/20) in the autologous iliac group, with no significant difference ( χ 2=0.176, P=0.675). Imaging review showed that grade Ⅰ bony fusion was obtained in both groups, and the fusion time of bone graft in the n-HA/PA66 group was significantly longer than that in the autologous iliac bone group ( P<0.05). There was no significant difference in the Cobb angle at each time point between the two groups ( P>0.05). No recurrence of tuberculosis, loosening or fracture of the internal fixator, or displacement of the bone graft was observed during follow-up. In elderly patients with lumbar spine tuberculosis, the n-HA/PA66 bioactive support combined with allogeneic bone graft can effectively restore and maintain the fusion segment height and physiological curvature of the lumbar spine, and the fusion rate of bone graft is similar to that of autologous iliac bone, which can achieve better effectiveness.

The Relationship Between Preoperative Cervical Sagittal Balance and Clinical Outcome of Acute Traumatic Central Cord Syndrome

To explore the sagittal radiological parameters related to clinical recovery of patients with acute traumatic central cord syndrome (ATCCS) and determine the diagnostic value of related variables. A retrospective review was performed of 104 patients with ATCCS. Six cervical sagittal balance parameters were collected: Cobb angle, T1 slope, neck tilt, thoracic inlet angle (TIA), C2-C7 sagittal vertex axis, T1 slope- C2-C7 Cobb angle. The patients were assigned to an ideal improvement group and poor improvement group according to their recovery rate. Receiver operating characteristic curve and area under the curve were used to evaluate the significant results of logistic regression and the optimal diagnostic value. Preoperative and postoperative Japanese Orthopaedic Association scores indicated a good recovery after surgical intervention. Radiological findings revealed that neck tilt and TIA were risk factors for poor neurological improvement of patients with ATCCS. Area under the curve (95% confidence interval) values of neck tilt and TIA were 0.763 (0.660-0.866) and 0.749 (0.643-0.855), and cutoff values were 39.1° and 65.6°, respectively. Lower neck tilt and TIA are risk factors for poor outcomes in patients with ATCCS after surgery. Neck tilt <39° and TIA <66° had significant diagnostic value for poor prognosis.

Lateral Patellar Facetectomy Reduces the Incidence of Anterior Knee Pain in Patellar Resurfaced Total Knee Arthroplasty.

Lateral patellar facet impingement (LPFI) can cause anterior knee pain (AKP) after patellar resurfaced total knee arthroplasty (TKA). Recently, lateral patellar facetectomy (LPF), which has been used for LPFI, has been performed during primary TKA, providing good clinical outcomes. However, the effect of LPF on AKP in primary patellar resurfaced TKA has not been sufficiently studied. The purpose of this study was to examine the effect of LPF on the development of AKP in patellar resurfaced TKAs with minimum follow-up of 3 years. This retrospective cohort study included 84 knees of 66 consecutive patients who underwent patellar resurfaced TKA between April 2007 and November 2014 in our hospital. The subjects were divided into two groups: TKA with LPF (LPF group; 47 knees) and TKA without LPF (no-LPF group; 37 knees). Postoperative AKP, the primary outcome, the Japanese Orthopaedic Association (JOA) score, and range of motion were investigated at the final visit and compared between the two groups. Six knees (16.2%) had AKP in the no-LPF group, whereas none of the knees had AKP in the LPF group at the final visit. The incidence of AKP was significantly lower in the LPF group (p = 0.004). The postoperative JOA score and flexion angle were significantly higher in the LPF group than in the no-LPF group. LPF correlated with less incidence of postoperative AKP and improved the JOA score and knee flexion angle. In patellar resurfaced TKA, LPF may be considered an additional maneuver to avoid postoperative AKP.

A Helpful Third Portal for Unilateral Biportal Endoscopic Decompression in Patients with Cervical Spondylotic Myelopathy: A Technical Note

Unilateral biportal endoscopic (UBE) laminotomy with bilateral decompression is a high-risk operation when performed in the cervical spine. In this study, we aimed to design an auxiliary portal for treatment of cervical spondylotic myelopathy using a percutaneous biportal endoscopic approach. Six patients with cervical spondylotic myelopathy were consecutively treated using an auxiliary portal (Zhang's portal) during percutaneous biportal endoscopic surgery between June 2020 and July 2021. Clinical outcomes were assessed by comparing preoperative and postoperative Japanese Orthopaedic Association scores and status based on modified Macnab criteria. The study enrolled 6 patients (2 men and 4 women; mean age, 51.6 ± 10.8 years). The mean operative time was 78.6 ± 37.4 minutes. There were no cases of infection, cerebrospinal fluid leakage, or neurological complications. The mean Japanese Orthopaedic Association score improved from 7.5 to 12.1. At final follow-up, outcomes were considered excellent for all patients based on modified Macnab criteria. Zhang's portal can allow for safe, flexible, and convenient contralateral decompression without the need to remove excessive portions of bone from the spinous process. Our results suggest that applying Zhang's portal in unilateral biportal endoscopy surgery represents an alternative when aiming to decompress the contralateral canal in patients with cervical spondylotic myelopathy caused by hypertrophy of the ligamentum flavum.

Anterior controllable antedisplacement and fusion: quantitative analysis of a single surgeon's learning experience

BACKGROUND CONTEXTAnterior controllable antedisplacement and fusion (ACAF) is a novel surgical technique for the treatment of ossification of the posterior longitudinal ligament (OPLL) but the surgical learning curve for this technique has not been previously characterized. PURPOSEThe aim of this study was to quantify a surgeon's learning curve for ACAF and the effect of surgeon experience on postoperative outcomes. STUDY DESIGNProspective study of a single institution and single surgeon experience with ACAF surgery. PATIENT SAMPLEA total of 70 consecutive patients with OPLL undergoing ACAF surgery by a single, non-ACAF trained surgeon between 2017 and 2020 were analyzed. OUTCOME MEASURESIntraoperative and postoperative outcomes (blood loss, operative time, errors of surgical procedure, length of hospital stay, Japanese Orthopedic Association (JOA) scoring system, and surgical complications) were assessed. METHODSWe prospectively reviewed the first 70 ACAF procedures between 2017 and 2020 performed by a single, non-ACAF trained surgeon. The function relationship between the operative time and case number was fitted using a locally weighted scatterplot smoothing (LOESS) plot. Spearman's correlation analysis was performed to determine factors affecting the operative time. The operative time-related learning curve for ACAF was established and difficulty of each procedure was assessed using a cumulative sum (CUSUM) model. The association between the specific errors of surgical procedures and surgeon experience was further analyzed. A modified CUSUM model was also used to establish the surgical procedure-related learning curve, and thus whether these two learning curves matched with each other was observed. Postoperative outcomes in relation to surgeon experience was compared using a Wilcoxon rank sum test and Chi-squared test. RESULTSOperative time presented a specific pattern of fewer patient-dependent changes as the case number increased. Spearman's correlation analysis showed the operative time was more affected by the case number (r=-0.73) than the complexity of condition and number of levels hoisted. The operative time-related CUSUM model identified the early (first 29 cases) and late phase (late 41 cases) of the learning process, which was also confirmed by a modified CUSUM model based on surgical procedure. The critical point of the CUSUM model for bilateral osteotomies was at case number 29, and time reduction after the early phase was approximately 34 minutes. Length of hospital stay and blood loss were less during the late phase than during the early phase (p<.05). Although no significant difference was observed in postoperative JOA scores between two phases, patients in the late phase obtained higher recovery rates of neurologic function than those in the early phase (p<.01). There was significant difference in the number of specific errors between the two phases (p=.02). There were no significant differences in overall complication rates between two phases, but a higher incidence of certain complications caused by specific errors was observed in the early phase (p=.02), including CSF leakage, C5 palsy and incomplete decompression. CONCLUSIONSWe described, for the first time, a detailed learning curve for ACAF surgery. About 29 cases were needed to achieve mastery of ACAF. Once mastered, the surgeon could deal with various OPLL presentations in a universal way regardless of condition complexity and number of surgical levels. Bilateral osteotomies were the most difficult part of ACAF and produced the greatest reduction in time after mastery. We found a close association between specific errors of surgical procedure for ACAF and surgeon experience. Furthermore, certain complications caused by these errors should be on the alert during the early phase of learning ACAF, including CSF leakage, C5 palsy and incomplete decompression.

Application of a new integrated low-profile anterior plate and cage system in single-level cervical spondylosis: a preliminary retrospective study

BackgroundAlthough ACDF has been widely used in treating cervical spondylosis and related diseases, the complications along with this anterior surgical technique have hindered its application and affected the postoperative outcome of the patients. Here, we investigated the clinical and radiological outcomes of a new integrated low-profile anterior plate and cage system for anterior cervical discectomy and fusion (ACDF) in treating cervical spondylosis.MethodsA total of 96 cervical spondylosis patients who underwent single-level ACDF between 2018 to 2020 in our institute were enrolled. There were 28 patients using the new implants and 68 patients using the zero-profile (Zero-P) implants. The Japanese Orthopedic Association (JOA) score and the visual analog scale (VAS) were used to evaluate the clinical outcomes. The cervical and segmental Cobb angle and range of motion (ROM) were used to assessed the radiological outcomes. Incidence of complications were also recorded. All data were recorded at pre-operation, 6-month and 12-month post-operation.ResultsAll patients were followed-up for at least 1-year, the mean follow-up time was over one year. The fusion rate was similar in the two groups. There was no significant difference in the postoperative JOA score recovery rate, postoperative VAS score of neck and arm pain, postoperative ROM, and incidence of complications between two groups (P > 0.05). However, postoperative cervical and segmental Cobb angle were better maintained in the new low-profile implant group compared to Zero-P group.ConclusionsThe clinical outcomes of the new low-profile implant were satisfactory and comparable to that of zero-profile system. It may have advantages in improving and maintaining the cervical lordosis, and can be an alternative device for single-level cervical spondylosis treated with ACDF.

Clinical application of enhanced recovery after surgery in lumbar disk herniation patients undergoing dynamic stabilization and discectomy

Enhanced recovery after surgery (ERAS) has been demonstrated to improve early postoperative outcomes and is becoming a crucial component of any perioperative management paradigm. To investigate the effect of an ERAS protocol on lumbar disk herniation (LDH) patients undergoing dynamic stabilization and discectomy. A total of 119 lumbar disk herniation (LDH) patients undergoing Dynesys dynamic stabilization and discectomy were divided into the ERAS (n1 = 56) and control group (n2 = 63). ERAS group received an enhanced recovery after surgery (ERAS) protocol, and control group received a traditional care protocol. Both the ERAS and control groups had significantly decreased visual analog scale (VAS) score and Oswestry Disability Index (ODI) and increased Japanese Orthopaedic Association (JOA) score at postoperative 1 week, 1 month and 3months compared with preoperative scores. Moreover, the ERAS group had lower postoperative VAS score and ODI and higher postoperative JOA score and rate of improved JOA score compared with the control group. Intraoperative blood loss, operation time, ambulation time and length of stay were all lower in the ERAS group than in the control group. The ERAS protocol designed was feasible for LDH patients undergoing dynamic stabilization and discectomy with significantly improved perioperative outcomes.

Stem-bone contact patterns of a long straight tapered uncemented stem for primary THA.

Despite excellent long-term survival, total hip arthroplasty (THA) can fail due to aseptic loosening, dislocations, sepsis and periprosthetic fractures, all of which remain considerably burdensome. Aseptic loosening is one of the main causes of THA failure, often due to osteolysis, stress shielding and/or lack of primary stability. This study aimed to investigate stem-bone contact patterns of a long straight-tapered uncemented stem following primary THA, and to determine whether these contact patterns are related to preoperative femoral morphology and whether they influence postoperative outcomes. The authors reviewed a continuous series of 60 hips (55 patients) that underwent primary THA using the Corail® stem (DePuy, Leeds, UK). Patients were evaluated pre- and post-operatively using the Japanese Orthopaedic Association (JOA) score. Computed-tomography (CT) scans were performed preoperatively to assess femoral bone morphology, and immediate postoperatively to assess stem-bone contact patterns. Postoperative radiographs were performed to calculate the Engh score. Regression analyses were performed to determine associations of postoperative JOA and Engh score with 27 independent variables. Forty-nine patients (54 hips) were assessed at 31 ± 8months, with a JOA score of 92.9 ± 8.1 and an Engh score of 21.2 ± 1.9. Six patients (6 hips) were lost-to-follow-up. There were no revisions and only one complication (recurrent dislocation). Stem-bone contact patterns were associated with preoperative femoral morphology (sagittal CFI [p = 0.006], femoral offset [p = 0.028], and NSA [p = 0.022]), but were not associated with either postoperative JOA or postoperative Engh score. The stem-bone contact patterns of a long straight-tapered uncemented stem are related to preoperative femoral morphology, but do not influence short-term postoperative outcomes. Contact patterns were related to preoperative femoral offset, NSA, and sagittal CFI, but not coronal CFI. Surgeons should, therefore, consider sagittal morphology for surgical planning and templating, in addition to the conventional parameters of coronal morphology.

Surgical resection of intradural extramedullary tumors in the atlantoaxial spine via a posterior approach.

BACKGROUNDThe anatomical features of the atlantoaxial spine increase the difficulty of complete and safe removal of atlantoaxial intradural extramedullary (IDEM) tumors. Studies concerning surgical interventions via a posterior approach are limited.AIMTo investigate the safety and efficacy of atlantoaxial IDEM tumor resection using a one-stage posterior approach.METHODSWe retrospectively analyzed clinical databases for one-stage atlantoaxial IDEM tumor resection via a posterior approach between January 2008 and January 2018. The analyzed data included tumor position, histopathological type, pre- and post-operative Japanese Orthopedic Association (JOA) scores and Nurick grades, postoperative complication and recurrence status.RESULTSA total of 13 patients who underwent C1-C2 Laminectomy and/or unilateral facetectomy via the posterior approach were enrolled in the study. In all cases reviewed, total tumor resection and concomitant C1-C2 fusion were achieved. The average follow-up was 35.3 ± 6.9 mo (range, 26-49 mo). A statistically significant difference was noted between the preoperative JOA score (11.2 ± 1.1) and the score at the last final follow-up (15.6 ± 1.0) (P < 0.05). A statistically significant difference was noted between the preoperative Nurick grade (2.3 ± 0.9) and that at the last follow-up (1.2 ± 0.4) (P < 0.05). However, no statistically significant difference was noted between the preoperative and last follow-up C1-2 Cobb angle and C2-7 Cobb angle (P > 0.05). No mortalities, severe complications or tumor recurrence were observed during the follow-up period. CONCLUSIONTotal resection of atlantoaxial IDEM tumors is feasible and effective via a posterior approach. Surgical reconstruction should be considered to avoid iatrogenic kyphosis and improve spinal stability and overall clinical outcomes.

Cervical Transdural Discectomy with Laminoplasty for the Treatment of Multi-segment Cervical Spinal Stenosis Accompanied with Cervical Disc Herniation: Technical Note and Clinical Outcome.

ObjectiveTo describe the surgical technique of cervical transdural discectomy with laminoplasty (CTDL) for the treatment of multi‐segment cervical spinal stenosis (CSS) accompanied with cervical disc herniation (CDH) and investigate its surgical outcomes and complications.MethodsThis was a clinical study. Between 2012 and 2018, 31 patients (13 males and 18 females) with multi‐segment CSS (over two cervical segments) accompanied with huge CDH and underwent CTDL were enrolled in this study. The details of CTDL technique with general anesthesia was described by the authors. The average follow‐up period of patients was 65.03 months (range from 24 to 126 months). Perioperative parameters such as age, sex, operative level, operative time, estimated blood loss, ambulation time, and operative complications were recorded. The results of clinical metrics such as the visual analog scale (VAS) and Japanese Orthopaedic Association (JOA) scores in the preoperative and during the follow‐up period were obtained and used to evaluate clinical outcomes. Radiographic improvement was evaluated by the compression ratio, sagittal maximum spinal cord compression (SMSCC), and cervical range of motion (ROM). The preoperative and postoperative follow‐up parameters (VAS, JOA, Compression ratio, SMSCC, and ROM) were assessed with paired t test. A P‐value <0.05 was considered statistically significant.ResultsIn the study, the mean age of the 31 patients was 55.23 ± 10.97 years. The mean operative time was 192.45 ± 24.17 min (ranging from 150 to 245 min), and intraoperative blood loss was 322.58 ± 129.00 mL (ranging from 150 to 600 mL). The VAS neck pain was improved significantly over the follow‐up period (P < 0.05, respectively). The VAS arm pain improved significantly from 6.26 ± 0.93 preoperatively to 1.74 ± 0.63 at 24 months postoperatively (P < 0.001). There was no significant difference in improvement of VAS arm pain between 24 months postoperatively and final follow‐up (P = 0.180). Compared with preoperative JOA score, JOA score was significantly improved at 24 months postoperatively (14.79 ± 1.84 vs 9.66 ± 2.81, P < 0.001). Meanwhile, there were no statistically significant differences between the final follow‐up and the postoperative JOA scores (15.08 ± 1.71 vs 14.79 ± 1.84, P = 0.051). Postoperative patients showed significantly higher index of compression ratio (58.30 ± 8.51 vs 27.17 ± 3.89, P < 0.001) and lower SMSCC (25.12 ± 5.67 vs 33.66 ± 5.38, P < 0.001). In addition, there was no significant difference between preoperative and postoperative cervical ROM (P = 0.740). One patient observed postoperative symptom of C6 nerve root injury, which was resolved within 24 months after the surgery; meanwhile, the neurological monitoring also reflected the intraoperative stretching of the C6 nerve root. Two cases involved postoperative cerebrospinal fluid (CSF) leakage which may have been related to laceration of dura mater.ConclusionsThis study suggested that CTDL technique could acquire satisfactory surgical outcomes for patients with multi‐segment CSS accompanied with CDH, but the surgical indications of the patients need to be selected strictly.

Low-Dose Collagenase Chemonucleolysis Combined with Radiofrequency in the Treatment of Lumbar Disc Herniation: A 10-Year Retrospective Study.

Objective This study explored the 10-year efficacy, safety, and prognostic factors of low-dose collagenase chemonucleolysis (CCNL) combined with radiofrequency (RF) in the treatment of lumbar disc herniation (LDH). Methods The data of 167 LDH patients were collected. Modified MacNab criteria, Numerical Rating Scale (NRS), and Japanese Orthopedic Association (JOA) scores were, respectively, used to evaluate patients' excellent and good rates, pain degree, and nerve function. The preoperative and 10-year postoperative patients' pain, numbness, and muscle weakness were compared. Patients' complications in perioperative period, recurrent/reappeared LDH, and reoperations were recorded. Finally, the independent risk factors affecting the long-time efficacy were assessed. Results A total of 126 patients were included. The patients' excellent and good rates were 86.51%–92.86% with no significant difference (P > 0.05). Postoperative NRS and JOA scores significantly improved (P < 0.01), most obvious within 6 months postoperatively. At 10 years postoperatively, 65.08%, 83.95%, and 93.02% of patients' pain, numbness, and muscle weakness were completely relieved (P < 0.05). Perioperative complications occurred in three patients with the rate of 2.38%. Recurrent/reappeared LDH patients were 11 with the ratio of 8.73%; nine of them underwent reoperations with the rate of 7.14%. And patients' probability of fair and poor efficacy at 10 years postoperatively with the course of disease >12 months and the responsibility disc ≥2 were, respectively, 6.005 and 4.227 times that of patients with the course of disease ≤12 months and the responsibility disc = 1 (P < 0.05). Conclusion The combined treatment is effective and safe in the long term. A course of disease >12 months and responsibility disc ≥2 independently reduce efficacy, and a course of disease >12 months has a more significant impact.