Postoperative Japanese Orthopaedic Association Research Articles

Radiographic and Clinical Results of C1 Laminoplasty for the Treatment of Compressive Myelopathy.

Study DesignCase series.PurposeTo evaluate the radiographic and clinical results of C1 laminoplasty without fusion.Overview of LiteratureC1 laminectomy has been the standard procedure for decompression at the C1 level. However, there have been some reports of trouble cases after C1 laminectomy. C1 laminoplasty might be superior to C1 laminectomy with regard to maintaining the original C1 anatomical shape, preventing compression from the posterior soft tissue, and ensuring an adequate bone-grafting site around the C1 posterior part if additional salvage fusion surgery is necessary afterward.MethodsSeven patients with spinal cord compression without obvious segmental instability at the C1/2 level treated by C1 laminoplasty were included. The indication of C1 laminoplasty was same as that of C1 laminectomy. C1 laminoplasty was performed in the same way as subaxial double-door laminoplasty. The imaging findings were evaluated using X-ray, computed tomography, and magnetic resonance imaging. The clinical results were evaluated using the Japanese Orthopaedic Association (JOA) Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) and JOA score. Peri- and postoperative complications were also investigated.ResultsNo patient showed increased C1/2 segmental instability after the surgery. The mean pre- and postoperative JOA scores were 8.6 and 11.7, respectively. The mean recovery rate was 40.2%. The effective rate in the JOACMEQ was 50% for the cervical spine function, 33% for the upper extremity function, 50% for the lower extremity function, 17% for the bladder function, and 17% for the quality of life. No major complication that seemed to be unique to C1 laminoplasty was observed over a period of about 4 years follow-up.ConclusionsC1 laminoplasty for patients without obvious segmental instability might be a viable alternative procedure to C1 laminectomy.

Influence of comorbid knee osteoarthritis on surgical outcome and sagittal spinopelvic/lower-extremity alignment in elderly patients with degenerative lumbar spondylolisthesis undergoing transforaminal lumbar interbody fusion.

This retrospective study aimed to clarify the influence of comorbid severe knee osteoarthritis (KOA) on surgical outcome in terms of sagittal spinopelvic/lower-extremity alignment in elderly patients with degenerative lumbar spondylolisthesis (DLS). In total, 110 patients aged at least 65 years (27 men, 83 women; mean age 74.0 years) who underwent short-segment lumbar fusion were included in the present study. Using the Kellgren-Lawrence (KL) grading system, patients were categorized into those with no to mild KOA (the mild-OA group: KL grades 0-2), moderate KOA (moderate-OA group: KL grade 3), or severe KOA (severe-OA group: KL grade 4). Surgical results were assessed using the Japanese Orthopaedic Association (JOA) scoring system, and spinopelvic/lower-extremity parameters were compared among the 3 groups. Adjacent-segment disease (ASD) was assessed over a mean follow-up period of 4.7 years (range 2-8.1 years). The study cohort was split into the mild-OA group (42 patients), the moderate-OA group (28 patients), and the severe-OA group (40 patients). The severe-OA group contained significantly more women (p = 0.037) and patients with double-level listhesis (p = 0.012) compared with the other groups. No significant differences were found in mean postoperative JOA scores or recovery rate among the 3 groups. The mean postoperative JOA subscore for restriction of activities of daily living was only significantly lower in the severe-OA group compared with the other groups (p = 0.010). The severe-OA group exhibited significantly greater pelvic incidence, pelvic tilt, and knee flexion angle (KFA), along with a smaller degree of lumbar lordosis than the mild-OA group both pre- and postoperatively (all p < 0.05). Overall, the rate of radiographic ASD was observed to be higher in the severe-OA group than in the mild-OA group (p = 0.015). Patients with ASD in the severe-OA group exhibited significantly greater pelvic tilt, pre- and postoperatively, along with less lumbar lordosis, than the patients without ASD postoperatively (all p < 0.05). A lack of lumbar lordosis caused by double-level listhesis and knee flexion contracture compensated for by far greater pelvic retroversion is experienced by elderly patients with DLS and severe KOA. Therefore, corrective lumbar surgery and knee arthroplasty may be considered to improve sagittal alignment, which may contribute to the prevention of ASD, resulting in favorable long-term surgical outcomes.

Choice of the Open Side in Unilateral Open-Door Laminoplasty for Cervical Ossification of the Posterior Longitudinal Ligament.

Retrospective study. To determine the optimal open side in unilateral open-door laminoplasty (UODL) for lateral cervical ossification of posterior longitudinal ligament (OPLL). No literature has reported which side of the vertebral arch should be chosen as the open side in UODL for lateral cervical OPLL. Patients with lateral cervical OPLL who were treated with UODL between 2013 and 2018 were retrospectively analyzed in two groups: Group A, where the open side was contralateral to the ectopic bone, and Group B, where the open side was ipsilateral to the ectopic bone. The Japanese Orthopaedic Association (JOA) Score, JOA recovery rate, spinal canal enlargement rate, cervical range of motion (ROM), and spinal cord area (SCA) were measured to evaluate and compare the clinical outcomes between the two groups. Statistical analysis was performed by t test and Hotelling T2 test. There was no significant difference in patient demographics and major complications between the two groups. The postoperative JOA Score and JOA recovery rate in Group A were significantly higher than those in Group B. There was no significant difference in cervical ROM within or between the two groups during the 2-year follow-up period, nor was there significant difference in spinal canal enlargement between the two groups. However, both postoperative SCA and increased SCA in Group A were significantly higher than those in Group B. The contralateral open side approach is preferable to the ipsilateral open side approach in UODL for lateral cervical OPLL. 3.

Applicability of the Conventional Suboccipital Approach for Resection of Foramen Magnum Meningiomas: Early Experience with a Case Series

Background Data: Foramen magnum (FM) meningiomas are always considered challenging cases for neurosurgeons. The challenge is even heftier with early experience with limited access to up-to-date neurosurgical gadgets. Besides the anatomical complexity of the region, FM meningiomas tend to grow in proximity to eloquent structures making the task even tougher. Multiple approaches have been advocated to manage these lesions; nevertheless, adopting an approach according to your experience and circumstances would be best. Purpose: To present our experience with 16 cases of FM meningiomas operated via posterior suboccipital approach and discuss the validity of this approach. Study Design: A retrospective cohort study. Patients and Methods: We reviewed our hospital records for patients where the posterior suboccipital approach was performed for foramen magnum meningiomas in the period between November 2014 and January 2019 at our institution. Lesions with anterior location or limited posterolateral extension and those with vertebral artery encasement were excluded. We could trace 16 patients with FM meningiomas operated upon using the midline suboccipital approach. Patients’ imaging included IV gadolinium-enhanced MRI brain and CT angiography including brain and neck for diagnostic and planning purposes. Recorded outcome variables were pre- and postoperative Japanese Orthopedic Association (JAO) scale, extent of tumor excision according to Simpson’s grading, operative blood loss, duration of surgery, hospital stay, and perioperative complications. Follow-up data were recorded from our outpatient clinic chart records. Results: Twelve patients were females and 4 were males with a mean age of 40.64±8.69 years (range, 29–56 years). The mean preoperative JOA score improved from 14.875±1.690 to 15.63±0.99 at the last postoperative follow-up. Total resection was achieved in 10 cases (6, grade I; 4, grade II), subtotal resection in 4 patients, and partial resection in 2 patients. Patients with residual lesions (N=6) were managed with Gamma Knife. The mean operative time was 261.25±55.33; the mean blood loss was 682.5±84.19; the mean hospital stay was 7.25±2.05 days. Transient CSF leak was the most common recorded complication (N=9). The mean follow-up period was 13±7.186 months. Conclusion: Our data suggest that the posterior midline suboccipital approach is a safe and effective option in the management of FM meningiomas that are mainly posterior or posterolateral. (2019ESJ203)

Comparative study of curative effect of spinal endoscopic surgery and anterior cervical decompression for cervical spondylotic myelopathy.

The aim of this study was to compare the clinical efficacy of endoscopic cervical spinal surgery with anterior cervical decompression and fusion (ACDF) in the treatment of cervical spondylotic myelopathy (CSM). A total of forty-six CSM patients who were admitted to the Medical School of Chinese PLA and treated with endoscopic spine surgery or ACDF from January 2015 to June 2017 were collected. The patients were divided into the spinal endoscopy group and the ACDF group, according to the operation methods. The operation time, intraoperative blood loss and hospitalization stay of the two groups were recorded and compared. Japanese Orthopaedic Association (JOA) score before operation, three months, and one year after operation were recorded for intra-group and inter-group comparison. The improvement rates of JOA were compared between the two groups to evaluate the clinical efficacy. There were twenty-two cases in the spinal endoscopy group and twenty-four cases in the ACDF group. The mean operation lasting time, intraoperative blood loss and hospitalization stay in the spinal endoscopy group were significantly lower than those in the ACDF group (P<0.05). The postoperative JOA score of the two groups were significantly higher than those before the operation (P<0.05). There were no significant differences in the JOA score before operation, three months and one year after operation between the two groups (P>0.05). The improvement rates in the spinal endoscopy group were not significantly different compared to those in the ACDF group (P>0.05). There was no significant difference in the excellent rate (81.8% vs. 83.3%) between the spinal endoscopy group and the ACDF group (P>0.05). The short-term efficacy of spinal endoscopic surgery and ACDF was equal in the treatment of CSM. The spinal endoscopic surgery was significantly superior to ACDF in reducing the operation time, the intraoperative blood loss and the hospitalization stay.

Percutaneous fixation assisted by O-arm-based navigation for thoracolumbar fractures without neurologic deficits

Objective To investigate the clinical efficacy of percutaneous fixation assisted by O-arm-based navigation for thoracolumbar fractures without neurologic deficits. Methods A retrospective case control study was conducted to analyze the clinical data of 35 thoracolumbar fracture patients without neurologic deficits admitted to Henan Provincial People's Hospital from January 2018 to December 2018. There were 26 males and 9 females, aged 17-51 years, with an average age of 30.4 years. The injured segments were distributed at T11 in 10 patients, T12 in 15, L1 in 11, and L2 in 4 patients. A total of 19 patients (22 vertebrae, 98 pedicle screws) were treated with O-arm guided navigation assisted percutaneous internal fixation (Group A), and 16 patients (18 vertebrae, 82 pedicle screws) were treated with C-arm guided percutaneous internal fixation (Group B). The operation time, accuracy rate of nail placement, complications, Cobb angle of fracture vertebral body, visual analogue score (VAS) and Japanese Orthopaedic Association (JOA) score were recorded and compared before operation, 7 days after operation and at the last follow-up. Results The patients were followed up for 2-12 months [(7.2±2.9)months] in Group A and 3-13 months [(7.1±3.3)months] in Group B. The operation time was (70.5±11.2)minutes in Group A and (81.3±10.9)minutes in Group B (P 0.05). The VAS at day 7 after operation was (2.3±1.1)points and (2.8±1.0)points in Group A and Group B, respectively, while the VAS at the final follow-up was (0.7±0.7)points and (0.8±0.7)points in Group A and Group B respectively. The postoperative VAS was significantly decreased compared with the preoperative VAS (P 0.05). The JOA at day 7 after operation was (21.1±2.2)points and (21.8±2.5)points in Group A and Group B respectively, while the JOA at the final follow-up was (24.9±2.2)points and (23.8±1.9)points in Group A and Group B respectively. The postoperative JOA was significantly increased compared with the preoperative JOA (P 0.05). Conclusion For thoracolumbar fractures without neurologic deficits, percutaneous fixation assisted by O-arm-based navigation can shorten the operation time and deliver a higher accuracy rate in the placement of pedicle screws, in addition to the similar effects with percutaneous fixation assisted by C-arm in pain relief, function improvement and correction of fracture vertebral kyphosis. Key words: Spinal fractures; Fracture fixation, internal; Navigation

Analysis of the spinal cord angle for severe cervical ossification of the posterior longitudinal ligament: comparison between anterior controllable antedisplacement and fusion (ACAF) and posterior laminectomy.

To investigate the changes of spinal cord angle between anterior controllable antedisplacement and fusion (ACAF) and posterior laminectomy in treating severe ossification of the posterior longitudinal ligament (OPLL). Seventy-one patients with cervical OPLL were enrolled. Patients in this study were divided into group A and group P. Japanese Orthopaedic Association (JOA) score was utilized to evaluate the neurological function. Radiological assessments included the spinal cord angle, Cobb angle, and area of the spinal cord. Surgery-related complications were also recorded. At the final follow-up, patients in group A had better recovery of local and whole cord angle, and the area of the cord than those in group P (all p < 0.05). A strong correlation between the change of local cord angle and the recovery of the spinal cord area was observed (r = - 0.867, p < 0.05). In addition, patients in group P had worse Cobb angle (9.15° ± 1.10°) than in group A (18.58° ± 0.73°) (p < 0.05). The final mean JOA score and its improvement rate were better in the group A than in group P (p < 0.05). During the follow-up, 15.15% patients in group P experienced surgery-related complications and 7.89% in group A. This present study revealed that ACAF can achieve better recovery of the expansion of the spinal cord, spinal cord alignment, and Cobb angle, with better postoperative JOA score and less complications, compared with posterior laminectomy in treating severe cervical OPLL. These slides can be retrieved under Electronic Supplementary Material.

Early and short-segment anterior spinal fusion for cervical spinal cord injury without fracture and dislocation can achieve more significant neurological recovery: a retrospective study based on the current medical system in southern China

ObjectiveThe purpose of this study was to investigate the effects of the number of fused segments, the timing of surgery and their interaction on the prognosis of patients with cervical spinal cord injury without fracture and dislocation (CSCIWFD), and to determine the appropriate time restrictions for early surgery in CSCIWFD patients based on the current diagnosis and treatment system in southern China.MethodsCSCIWFD patients who underwent anterior cervical decompression and internal fusion (ACDF) from January 2012 to June 2017 were selected. The patients were grouped according to the timing of surgery and the number of fused segments and evaluated based on their American Spinal Injury Association (ASIA) score, ASIA impairment scale, and Japanese Orthopaedic Association (JOA) score before and after surgery. SPSS22.0 software was used for the statistical analysis.ResultsThe ASIA score, JOA score, and ASIA impairment scale in all follow-ups were significantly higher than before surgery (p < 0.05). The ASIA and JOA scores at 6, 12, and 24 months after surgery of the patients who underwent ACDF within 72 h were significantly better than those of the patients who underwent ACDF after 72 h (p < 0.05). There were significant differences in postoperative ASIA and JOA scores at 12 and 24 months between the short-segment and three-segment fusion groups (p < 0.05). The results of the interaction between the surgical timing and the number of the fused segments showed that the postoperative ASIA and JOA scores at 6, 12, and 24 months were significantly higher in the patients who underwent early short-segment fusion than in those who underwent delayed short-segment fusion (p < 0.05). However, no statistically significant difference was found between early and delayed surgery in the patients who underwent three-segment fusion (p > 0.05).ConclusionACDF is safe and effective for the treatment of CSCIWFD. For patients with single- or double-segment injury, early (within 72 h) ACDF is associated with a more satisfactory prognosis. Due to the limitation of the small sample size, we cautiously recommend that 72 h can be used as a time limit for early surgery for CSCIWFD patients in regions where earlier surgery cannot be provided by the current diagnosis and treatment system.

Connection of discontinuous segments in early functional recovery from thoracic ossification of the posterior longitudinal ligament treated with posterior instrumented surgery.

The objective of this study was to investigate the relationship between morphological changes in thoracic ossification of the posterior longitudinal ligament (T-OPLL) and postoperative neurological recovery after thoracic posterior fusion surgery. Changes of OPLL morphology and postoperative recovery in cases with T-OPLL have not been examined. In this prospective study, the authors evaluated data from 44 patients (23 male and 21 female) who underwent posterior decompression and fusion surgery with instrumentation for the treatment of T-OPLL at our hospital. The patients' mean age at surgery was 50.7 years (range 38-68 years). The minimum duration of follow-up was 2 years. The location of thoracic ossification of the ligamentum flavum (T-OLF), T-OLF at the OPLL level, OPLL morphology, fusion range, estimated blood loss, operative time, pre- and postoperative Japanese Orthopaedic Association (JOA) scores, and JOA recovery rate were investigated. Reconstructed sagittal multislice CT images were obtained before and at 3 and 6 months and 1 and 2 years after surgery. The basic fusion area was 3 vertebrae above and below the OPLL lesion. All parameters were compared between patients with and without continuity across the disc space at the OPLL at 3 and 6 months after surgery. The preoperative morphology of OPLL was discontinuous across the disc space between the rostral and caudal ossification regions on sagittal CT images in all but one of the patients. Postoperatively, these segments became continuous in 42 patients (97.7%; occurring by 6.6 months on average) without progression of OPLL thickness. Patients with continuity at 3 months had significantly lower rates of diabetes mellitus (p < 0.05) and motor palsy in the lower extremities (p < 0.01). The group with continuity also had significantly higher mean postoperative JOA scores at 3 (p < 0.01) and 6 (p < 0.05) months and mean JOA recovery rates at 3 and 6 months (both p < 0.01) after surgery. Preoperatively, discontinuity of rostral and caudal ossified lesions was found on CT in all patients but one of this group of 44 patients who needed surgery for T-OPLL. Rigid fixation with instrumentation may have allowed these segments to connect at the OPLL. Such OPLL continuity at an early stage after surgery may accelerate spinal cord recovery.

Short-term effectiveness of axis laminar screws for reducible atlantoaxial dislocation

To investigate reliability and short-term effectiveness of axis laminar screws for reducible atlantoaxial dislocation (RAAD). A clinical data of 41 patients with RAAD who were admitted between February 2013 and February 2018 and met the inclusion criteria was retrospectively analyzed. The atlases in all patients were fixated by lateral mass screws, and the axes were fixed by laminar screws in 13 cases (LS group) and by pedicle screws in 28 cases (PS group). There was no significant difference in gender, age, and preoperative Japanese Orthopedic Association (JOA) score between the two groups ( P>0.05). The effectiveness was estimated by post-operative JOA score; and the accuracy of the axis screw, atlantoaxial bone graft fusion, and the fixation stability were examined by X-ray film and CT. All incisions healed by first intention. All patients were followed up 12-17 months (mean, 13.8 months) in LS group and 12-20 months (mean 14.1 months) in PS group, and the difference in follow-up time was not significant ( Z=-0.704, P=0.482). At last follow-up, JOA scores were 13.9±1.6 in LS group and 14.3±1.8 in PS group, which significantly improved when compared with the pre-operative scores in the two groups ( t=-9.033, P=0.000; t=-15.835, P=0.000); while no significant difference was found between the two groups ( t=-0.630, P=0.532). Twenty-five screws of 26 screws in LS group and 54 screws of 56 screws in PS group were implanted accurately, with no significant difference in the accuracy of the axis screw between the two groups ( Z=-0.061, P=0.951). All patients obtained atlantoaxial bone graft fusion, except 1 case in PS group. There was no significant difference in the atlantoaxial bone graft fusion between the two groups ( Z=-0.681, P=0.496). For RAAD, Axis laminar screws can maintain the atlantoaxial primary stability and had a good short-term effectiveness. So, it could be an alternative and reliable technique for axis screw.

Postoperative Resolution of MR T2 Increased Signal Intensity in Cervical Spondylotic Myelopathy: The Impact of Signal Change Resolution on the Outcomes.

A prospective comparative imaging study. This study investigated whether postoperative resolution of spinal cord increased signal intensity (ISI) reflected symptom improvement and surgical outcomes in cervical spondylotic myelopathy (CSM) patients. Although some CSM patients exhibit magnetic resonance imaging (MRI) ISI, its alteration and resolution have not been investigated. The association between postoperative ISI resolution and surgical outcomes in CSM patients remains controversial. A total of 505 consecutive CSM patients (311 males; 194 females) aged a mean of 66.6 years (range, 41-91) were enrolled. All were treated with laminoplasty and underwent MRI scans preoperatively and after an average of 26.5 months postoperatively (range 12-66 months). ISI was classified pre- and postoperatively based on sagittal T2-weighted magnetic resonance images into Grade 0, none; Grade 1, light (obscure); and Grade 2, intense (bright). The patients' pre- and postoperative neurological statuses were evaluated using the Japanese Orthopedic Association scoring system for cervical myelopathy [Japanese Orthopedic Association (JOA) score] and other quantifiable tests, including the 10-s grip and release (10-s G&R) test and 10-s step test. A total of 337 patients showed preoperative ISI. Among these, 42 (12.5%) showed postoperative ISI resolution, associated with better postoperative JOA score and recovery rate, 10-s G&R and 10-s step test scores than those who retained it. Patients with preoperative Grade 2 ISI had no postoperative ISI resolution. Patients with ISI improvement from Grade 1 to Grade 0 had better outcomes than those with ISI worsening from Grade 1 to Grade 2. Postoperative ISI resolution in CSM patients reflects postoperative symptoms and surgical outcomes. Patients who exhibit ISI resolution have better clinical outcomes. 3.

Comparative Effectiveness and Functional Outcome of Open-Door versus French-Door Laminoplasty for Multilevel Cervical Myelopathy: A Meta-Analysis.

BACKGROUND:At present, few reports are comparing these 2 major cervical posterior laminoplasty methods with Open-door and French-door Laminoplasty in terms of neurological recovery, cervical alignment, and surgical complications. Moreover, most of the research has not been well designed.AIM:This study aims to determine comparative effectiveness and functional outcome of open-door versus french-door laminoplasty for multilevel cervical myelopathy.METHODS:The Meta-analysis is used in this study. The study sample is a published research articles on comparative effectiveness and functional outcome of open-door versus french-door laminoplasty for multilevel cervical myelopathy on the internet through databases on PubMed and ProQuest and published between 1997 until December 2018. Weighted mean difference and pooled weighted mean difference are calculated by using the fixed-effect model or random-effect model. Data is processed by using Review Manager 5.3 (RevMan 5.3).RESULTS:This study reviews 58 articles. There are 6 studies conducted a systematic review and continued with Meta-analysis of relevant data. The results showed significant higher postoperative Japanese Orthopaedic Association (JOA) score in open-door laminoplasty (ODL) than French-door laminoplasty (FDL) (weighted mean difference [WMD] = 0.71; 95% confidence interval [CI]: 0.35 to 1.07; p < 0.05). The outcome of procedures treatment of multilevel cervical myelopathy revealed the operative time, cervical range of motion, axial canal diameter postoperative, axial pain reduction and complications events in ODL and FDL there was no significant difference. But for a cervical lordotic angle in ODL and FDL, there was a significant difference; the ODL group were significantly lesser than the FDL group. The recovery rate in ODL and FDL, there was a significant difference; the ODL was shown to be significantly higher than FDL (p < 0.05).CONCLUSION:This analysis suggests that neither cervical laminoplasty approach is superior, based on the postoperative radiological data and complication rate. But the open-door laminoplasty resulted in a higher functional outcome and recovery rate as compared to the French-door laminoplasty.

Recovery Process After Anterior Cervical Decompression in Patients With Cervical Spondylotic Myelopathy With Different Natural History.

An observational prospective cohort study. To investigate the influence of natural history on the recovery of patients with cervical spondylotic myelopathy (CSM) after anterior cervical decompression. The natural history of CSM has not been clearly elucidated, it remains unclear whether the natural history of CSM is associated with the recovery process after surgical treatment. Patients with CSM (n=117) after anterior cervical decompression were stratified variously on the basis of natural history features. Baseline and postoperative neurological functions were rated using the Japanese Orthopaedic Association (JOA) and patient-based self-evaluation (PBSE) scores. The minimum and maximum recovery times for sensory function, and motor functions of the upper and lower extremities were analyzed separately at time points 1-60 months after surgery. In all patients, the postoperative JOA and PBSE scores were significantly improved relative to baseline, in which sensory function recovered most quickly, followed by upper-extremity and lower-extremity motor functions. However, when compared with patients whose first symptom onset at the lower extremity, patients with the first onset at the upper extremity required less time to recover lower-extremity motor function, but more time to recover upper-extremity motor function. Patients with rapid progression had significantly lower preoperative and final JOA and PBSE scores compared with patients whose progression was steady or stepwise. Patients with preoperative symptoms ≥1 year had longer recovery time and poorer functional outcomes compared with those symptoms <1 year. In patients with CSM, the location of first symptom onset, progressive velocity of symptom, and duration of preoperative symptoms significantly influenced the recovery process after anterior cervical decompression. Level 2-observational prospective study.

Comparison of Posterior Lumbar Interbody Fusion and Microendoscopic Muscle-preserving Interlaminar Decompression for Degenerative Lumbar Spondylolisthesis With &gt;5-Year Follow-up

Retrospective analysis of prospectively collected observational multicenter data. To compare the clinical results and rates of revision surgery after posterior lumbar interbody fusion (PLIF) and microendoscopic muscle-preserving interlaminar decompression (ME-MILD) in patients with single-level, mild degenerative lumbar spondylolisthesis (DLS) and follow-up of at least 5 years. Surgery for symptomatic DLS remains controversial. Evaluating long-term results may reveal problems such as adjacent segmental diseases of the PLIF and decreased quality of life because of slippage and restenosis of the ME-MILD. We enrolled 116 patients who underwent PLIF (79 patients) or ME-MILD (37 patients). Operative times, blood losses, surgical complications, Short-Form 36 (SF-36), Japanese Orthopedic Association (JOA) score, the JOA Back Pain Questionnaire (JOABPEQ), visual analog scales (VAS), and Zurich Claudication Questionnaire (ZCQ) were evaluated. PLIF was observed to require significantly longer operative times and entailed greater operative blood losses than did ME-MILD (151.1 vs. 119.9 min; 202.2 vs. 6.4 mL, respectively). Surgery-related complications were identified in 3 cases in the PLIF group and 2 cases in the ME-MILD group. Seventy-eight patients (50 and 28 patients in the PLIF and ME-MILD groups, respectively) were successfully followed-up for >5 years. The follow-up rate was 67.2%. No significant differences between the groups were found in terms of preoperative and postoperative JOA scores, postoperative JOABPEQ, VAS, or ZCQ. Significant improvements in JOA scores were observed in both groups. Significant improvements in the SF-36 were observed in all subscales except in role physical, general health, vitality, and mental health in the ME-MILD group. Revision surgical procedures were performed in 2 patients in the ME-MILD group and 4 patients in the PLIF group. PLIF and ME-MILD resulted in equivalent improvements in SF-36 and JOA scores. There were no differences in revision surgery rates among patients with single-level, mild DLS. Level III-a retrospective analysis.

Is Modified K-line a Powerful Tool of Surgical Decision Making for Patients With Cervical Spondylotic Myelopathy?

Prospective observational single-center study. To evaluate anterior decompression and fusion (ADF) or posterior surgery (PS) for patients with cervical spondylotic myelopathy (CSM) using the modified K-line (mK-line) and to compare clinical and radiologic outcomes between these 2 techniques. The authors have previously reported that insufficient posterior decompression is often seen after laminoplasty for CSM in patients with preoperative anterior clearance of the spinal cord <4 mm on the basis of the mK-line. However, to our knowledge, no study has investigated the role, if any, of the mK-line in surgical decision making for patients with CSM. A total of 87 patients were enrolled who underwent surgery for treatment of CSM between 2011 and 2015 at our hospital and who could be followed up for at least 2 years. ADF was selected as a more favorable procedure than PS in patients with anterior spinal clearance of <4 mm on preoperative midsagittal magnetic resonance imaging. On the basis of the Japanese Orthopedic Association (JOA) scoring system for cervical myelopathy, the rate of recovery of the JOA scores at 2 years after surgery was investigated as a clinical outcome to compare these 2 groups. Mean age was 65.1 (±12.9) years in the ADF group (n=26) and 70.5 (±8.6) years in the PS group (n=61). In the PS group, 10 patients underwent posterior decompression with fusion. Mean preoperative and postoperative JOA scores were 10.5 and 14.1 points in the ADF group and 9.8 and 13.1 points in the PS group, respectively, showing no significant difference in recovery rate of JOA score between the ADF (58.9%) and PS (47.1%) groups. However, patients with a minimum interval between the mK-line and the anterior compression factor on the midsagittal image (minimum interval of the spinal cord) <4 mm tended to have unsatisfactory outcomes (recovery rate 29.6%) compared with patients with minimum interval of the spinal cord >4 mm (53.6%, P=0.07) in the PS group. Preoperative intervention using the mK-line is useful to predict residual cord compression and might homogenize postoperative clinical outcomes in both anterior surgery and PS.

Surgical Technique and Clinical Outcomes of Osteochondral Autograft Transplantation for Large Osteonecrotic Lesions of the Femoral Condyle With Residual Normal Cartilage: The Eyeglass Technique.

Background:Osteochondral autograft transplantation (OAT) is usually performed for a defect that is <400 mm2 because of the limitations of autografts.Purpose:To present the surgical technique and clinical outcomes of OAT using the eyeglass technique for large osteonecrotic lesions of the femoral condyle (LOFs) (>400 mm2) with residual normal cartilage.Study Design:Cohort study; Level of evidence, 3.Methods:Cases (group 1) included 15 patients (18 knees) who underwent OAT using the eyeglass technique for LOFs with residual normal cartilage, while controls (group 2) included 11 patients (11 knees) who underwent OAT using the standard technique for small osteonecrotic lesions of the femoral condyle (≤400 mm2). Clinical outcomes were evaluated preoperatively and at the final follow-up (group 1, 56 months; group 2, 48 months) according to the International Knee Documentation Committee (IKDC) objective grade, the IKDC subjective score, and the Japanese Orthopaedic Association (JOA) score.Results:The mean lesion size was 685 mm2 in group 1 and 230 mm2 in group 2. Patients in group 1 had postoperative scores equivalent to those in group 2. The postoperative IKDC subjective scores in group 1 (mean, 86.9) and group 2 (mean, 87.0) showed no significant difference at the final follow-up (P = .653). For postoperative IKDC objective grades, 83.3% of group 1 and 81.8% of group 2 were graded as “nearly normal” or better, and no significant intergroup difference was found for the IKDC objective grade (P = .989). Also, no significant intergroup difference was found for the postoperative JOA score (group 1, 93.9; group 2, 81.4; P = .480). Nine second-look arthroscopic procedures were performed in group 1 compared with 4 in group 2, and all patients had plugs that were graded as “nearly normal” or better by the International Cartilage Repair Society classification system.Conclusion:The postoperative results of patients who underwent OAT using the eyeglass technique for large osteonecrotic lesions (>400 mm2) were equivalent to the results of patients who underwent OAT using the standard technique for small osteonecrotic lesions (≤400 mm2).

Cervical Range of Motion after Anterior Corpectomy and Fusion versus Laminoplasty for Multilevel Cervical Spondylotic Myelopathy: A Three-Dimensional Comparison Based on the Coda Motion System

To compare the change in cervical range of motion (CROM) after the 2 most widely used techniques for multilevel cervical spondylotic myelopathy (CSM): anterior cervical corpectomy and fusion (ACCF) and laminoplasty. Patients with multilevel CSM treated in our hospital between 2014 and 2018 were divided into an ACCF group and a laminoplasty (LAMP) group according to the treatment received. Their demographic data, preoperative and postoperative Japanese Orthopedic Association (JOA) scores, and CROM, measured using the Coda Motion system, were analyzed and compared. A total of 53 patients were enrolled, including 29 patients in the ACCF group and 24 patients in the LAMP group. Age, sex, duration of follow-up, and preoperative and postoperative JOA scores were comparable in the 2 groups. Compared with preoperative measurements, ACCF group lost an average of 9.8%, 28.5%, 8.9%, 9.9%, 10.6%, and 7.8% of their CROM in flexion, extension, left and right lateral flexion, and left and right rotation, respectively, at the latest follow-up. For the LAMP group, these average losses were 3.5%, 16.4%, 3.2%, 6.3%, 7.0%, and 5.7%, respectively. Thus, the ACCF group exhibited greater average CROM loss than the LAMP group in all directions at the latest follow-up. Both ACCF and laminoplasty cause significant CROM loss in patients with multilevel CSM. The laminoplasty technique preserved more CROM than ACCF in all 6 directions after at least 1 year of follow-up. These results can be used when counseling patients undergoing surgery.

Extensor muscle-preserving laminectomy in treating multilevel cervical spondylotic myelopathy compared with laminoplasty.

Laminectomy and laminoplasty are popularly used in posterior cervical spine surgery but still have involved complications. We aimed to compare the clinical outcomes of microscope-assisted extensor muscle-preserving laminectomy (MA-EMPL) and open-door laminoplasty (ODLP) in treating multilevel cervical spondylotic myelopathy (MCSM). A prospective study was designed to enroll twenty patients with MCSM underwent MA-EMPL, and recruit twenty-four patients with MCSM received ODLP (control). Radiographic measurements, outcome indicators including Japanese Orthopedic Association (JOA) score and visual analogue score (VAS) were used to evaluate technical effectiveness. Surgical complications were documented to assess technical safety. Postoperative cervical curvature index and range of neck motion (ROM) were not significantly changed except ROM in ODLP group. Postoperative JOA score and VAS in both groups showed improvements at final follow-up. There was no statistical difference in postoperative neurological recovery rates between two groups (67.6%±17.8% vs. 70.15%±19.6%, P=0.632). However, VAS was significantly lower at postoperative 1 month in MA-EMPL group compared with ODLP group (P<0.001). The incidences of C5 palsy were 0 vs. 16.7% between MA-EMPL group and ODLP group. There was no axial symptom occurred in MA-EMPL group while six patients in ODLP group (0 vs. 25%, P=0.049). In addition, the mean blood loss and hospital stay were lesser in MA-EMPL group compared with ODLP group (P<0.001, P=0.002, respectively). MA-EMPL is an effective, safe and minimally invasive method in treatment of MCSM. Compared with ODLP, MA-EMPL has advantage to decrease intraoperative blood loss, hospital stay, postoperative VAS and axial symptom, as well as preserve postoperative ROM.

To Determine the Surgical Outcome of Anterior Cervical Corpectomy and Fusion without Fixation for Ossification of Posterior Longitudinal Ligament.

Aims:The purpose of our study is to evaluate the surgical outcome in patients undergoing anterior cervical corpectomy without fixation with plates and screws for the treatment of ossification of posterior longitudinal ligament (OPLL).Subjects and Methods:The type of study was case series and was conducted from January 2015 to December 2015 for 1-year duration at the Department of Neurosurgery at a Tertiary Care hospital in Karachi, Pakistan. A total of n = 20 patients (16 men and 4 women; mean age of 57.45 ± 6.4 years [range: 45–68 years]) were included after thorough clinical history and physical examination. Neurological evaluation was done using the Japanese Orthopedic Association (JOA) scoring system. The pre- and post-operative JOA scores were used to calculate recovery rate (RR) of the patients. Radiographic assessment was done using various modalities such as X-ray, computed tomography scan, and magnetic resonance imaging. Surgical outcome and complications were studied and the data were analyzed using SPSS 21.Results:After the uniform follow-up period of 12 months, mean JOA scores improved from 9.1 ± 1.37 preoperatively to 14.3 ± 1.69 postoperatively and mean RR was 67.01 ± 15.5%. All the patients showed successful osseous fusion while one patient did not. Two patients developed cerebrospinal fluid leakage, one patient developed recurrent laryngeal nerve palsy, and one expired due to iatrogenic neurological deterioration.Conclusion:Anterior cervical corpectomy without fixation with plates and screws is an effective surgical procedure for the treatment of OPLL (for up to three cervical levels of OPLL). It gives good neurological recovery with fewer postoperative complications.

Clinical application of para-split laminotomy in the treatment of lumbar spinal canal tumors

Objective To explore the feasibility and effectiveness of para-split laminotomy in the treatment of lumbar spinal canal tumors. Methods We retrospectively reviewed the clinical data of 15 patients with lumbar spinal canal tumors who underwent tumor resection following para-split laminotomy at Department of Neurosurgery, Clinical Medical College of Yangzhou University from October 2016 to May 2018. Observation indicators included intraoperative blood loss, surgical duration, tumor resection, tumor pathological results and complications.Neurological functions of the spinal cord evaluated based on JOA (Japanese Orthopedic Association) scoring system. The follow-up situations included tumor recurrence, spinal stability evaluation and bone fusion of laminae. Results All lumbar spinal canal tumors were resected completely. The mean blood loss was 95.3±58.2 ml and the mean duration of the surgical procedure was 176.7±35.2 min. In this group, the average preoperative JOA score was 15.5±4.9 and the average postoperative JOA score was 24.0±3.5, which was improved significantly (P<0.01). There were no operative complications occurring. The CT examination showed no pedicle or vertebral fractures. During the follow-up period of 6-18 months (average: 10.8±3.9 months), no tumor recurrence or spinal deformation was found according to the imaging examination. CT examination showed that the split laminae tended to heal in the operative area. Conclusion The para-split laminotomy shows minimally invasive damage to the posterior spinal tension band and helps to protect the stability of the spine. It is feasible and effective to apply the para-split laminotomy in the operation of lumbar spinal canal tumors. Key words: Spinal canal; Neoplasms; Neurosurgical procedures; Laminotomy