Visual Analog Scale Neck Pain Research Articles

Surgical complications and incomplete canal widening of the vertebral body sliding osteotomy to treat cervical myelopathy.

Vertebral body sliding osteotomy (VBSO) is a surgical technique that anteriorly translates the vertebral body with compressive lesions and achieves cord decompression through canal widening. However, data on the surgical complications of VBSO are lacking. Furthermore, it has not been known whether VBSO could be a viable alternative in the treatment of cervical myelopathy even when the preoperative canal-occupying ratio (COR) is large, which seems to frequently result in incomplete canal widening. This study aimed to describe the incidence of VBSO-associated surgical complications and to evaluate the incidence and risk factors of incomplete canal widening. A total of 109 patients who underwent VBSO to treat cervical myelopathy were retrospectively reviewed. Neck pain visual analog scale, Neck Disability Index, Japanese Orthopaedic Association (JOA) scores, and surgical complications were evaluated. For radiological evaluation, C2-7 lordosis, C2-7 sagittal vertical axis, and COR were measured. Patients with a preoperative COR < 50% (n = 60) and those with a COR ≥ 50% (n = 49) were compared and logistic regression analysis was performed to identify factors associated with incomplete canal widening. The most frequent complication in the patients was mild dysphagia (7.3%). Dural tears were observed during posterior longitudinal ligament resection (n = 1) and foraminotomy (n = 1). Two patients underwent reoperation due to radiculopathy from adjacent-segment disease. Incomplete canal widening occurred in 49 patients. According to logistic regression analysis, high preoperative COR was the only factor associated with incomplete canal widening. The amount of canal widening and JOA recovery rate in the COR ≥ 50% group were significantly higher than in the COR < 50% group. Mild dysphagia was the most common complication following VBSO. Although VBSO aims to decrease the complication rate of corpectomy, it was not free of dural tears. Special care would be required during the posterior longitudinal ligament resection. Incomplete canal widening occurred in 45.0% of patients, and high preoperative COR was the only risk factor for incomplete canal widening. However, high preoperative COR would not be a contraindication for VBSO, given that favorable clinical outcomes were presented in the COR ≥ 50% group.

Comparison of Anterior Cervical Decompression and Fusion and Posterior Laminoplasty for Four-Segment Cervical Spondylotic Myelopathy: Clinical and Radiographic Outcomes.

Although anterior or posterior surgery for cervical spondylotic myelopathy (CSM) has been extensively studied, the choice of anterior or posterior approach in four-segment CSM remains poorly studied and controversial. We compared the clinical and radiographic outcomes of four-segment CSM by posterior laminoplasty (LAMP) and anterior cervical decompression fusion (ACDF) to further explore the merits and demerits of ACDF and LAMP for four-segment CSM in this study. Patients with four-segment CSM who underwent ACDF or LAMP between January 2016 and June 2019 were retrospectively analyzed. We compared the preoperative and postoperative cervical Japanese Orthopaedic Association (JOA) scores, neck disability index (NDI), neck pain visual analog scale (VAS) score, sagittal vertical axis, cervical lordosis (CL), and range of motion. There were 47 and 79 patients in the ACDF and LAMP groups, respectively. Patients in the ACDF group had a significantly longer surgical time and lower estimated blood loss and length of stay than those in the LAMP group. There was no significant difference in the JOA, NDI, or neck pain VAS scores between the two groups preoperatively, but the NDI and neck pain VAS scores in the ACDF group were significantly lower than those in the LAMP group at the final follow-up. The preoperative C2-C7 Cobb angle of the ACDF group was significantly lower than that of the LAMP group but there was no significant difference between the two groups postoperatively. The improvement of C2-C7 Cobb angle (∆C2-C7 Cobb angle) in the ACDF group was significantly higher than that in the LAMP group. This indicated that ACDF can improve CL better than LAMP. The linear regression analysis revealed the ∆C2-C7 Cobb angle was negatively correlated with the final follow-up neck pain VAS scores and NDI. This indicated that patients with better improvement of CL may have a better prognosis. Although both ACDF and LAMP surgeries are effective for four-segment CSM, ACDF can better improve CL and neck pain. For patients with poor CL, we suggest ACDF when both approaches are feasible.

Patient-Reported Allergies Do Not Affect Long-Term Patient-Reported Outcome Measures After Spine Surgery.

A gap in the literature exists regarding the association between number of allergies and patient-reported outcomes measures (PROMs) for patients undergoing spine surgery. Consecutive cervical or lumbar spine surgery patients were identified from a prospective registry from April 2017 to July 2020. Patients were grouped into those with 0, 1, 2, or ≥3 allergies. Demographics were compared between the groups. PROMs included Neck Disability Index, Oswestry Disability Index, visual analog scale (VAS) neck pain, VAS arm pain, VAS back pain, VAS leg pain, short form 12 (SF-12) physical component score, SF-12 mental component score, and patient-reported outcomes measurement information system physical function (PROMIS-PF), and outcomes were compared between the groups through multivariable analysis at up to 1-year follow-up. Associations between number of allergies and achieving a minimal clinically important difference (MCID) in the 9 aforementioned PROMs at 1-year follow-up were assessed. This study included 148 cervical and 517 lumbar patients. After controlling for demographic differences, a higher number of allergies was associated with less improvement in VAS neck pain, SF-12 physical component score, and PROMIS-PF at 12 weeks following cervical surgery and less improvement in PROMIS-PF at 2 weeks following lumbar surgery (P < 0.05). However, these associations failed to persist after 6 months and 12 weeks following surgery in cervical and lumbar patients, respectively (P > 0.05). No association was identified between number of allergies and achievement of MCID in any of the 9 studied PROMs at 1-year follow-up. The higher number of allergies was associated with less improvement in PROMs in the early postoperative period but not at longer-term follow-up. These findings provide data that can be utilized while counseling patients and setting postoperative expectations.

Short-Term Neck Pain After Posterior Foraminotomy Compared with Anterior Discectomy with Fusion for Cervical Foraminal Radiculopathy: A Secondary Analysis of the FACET Randomized Controlled Trial.

Short-term neck pain after posterior cervical foraminotomy (posterior surgery) compared with anterior cervical discectomy with fusion (anterior surgery) treating cervical radiculopathy has only been assessed once, retrospectively, to our knowledge. The aim of this study was to prospectively evaluate the course of neck pain for 6 weeks after both treatments. This is a secondary analysis of the multicenter Foraminotomy ACDF Cost-Effectiveness Trial (FACET), conducted from January 2016 to May 2020. Of 389 patients who had single-level, 1-sided cervical radiculopathy and were screened for eligibility, 265 were randomly assigned to undergo posterior surgery (n = 132) or anterior surgery (n = 133). The primary outcome of the present analysis was neck pain, assessed weekly for 6 weeks using the visual analog scale (VAS), on a scale of 0 to 100. The secondary outcomes were arm pain, neck disability, work ability, quality of life, treatment satisfaction, motor and sensory changes, and hospital length of stay. Data were analyzed with mixed model analysis in intention-to-treat samples using 2-sided 95% confidence intervals (CIs). In the first postoperative week, the mean VAS for neck pain was 56.2 mm (95% CI, 51.7 to 60.8 mm) after posterior surgery and 46.7 mm (95% CI, 42.2 to 51.2 mm) after anterior surgery. The mean between-group difference was 9.5 mm (95% CI, 3.3 to 15.7 mm), which gradually decreased to 2.3 mm (95% CI, -3.6 to 8.1 mm) at postoperative week 6. As of postoperative week 5, there was no significant difference between groups. Responder analyses confirmed this result. Secondary outcomes showed small differences between groups. Insight into the course of neck pain during the first 6 weeks after posterior compared with anterior surgery is provided. Despite initially more neck pain after posterior surgery, patients swiftly improved and, as of postoperative week 5, results similar to those after anterior surgery were observed. Our findings should enable improved patient counseling and enhanced shared decision-making between physicians and patients with cervical radiculopathy, where more neck pain in the first postoperative weeks should be balanced against the benefits of posterior surgery. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Vertebral Body Sliding Osteotomy as a Surgical Strategy for the Treatment of Cervical Myelopathy: Outcomes at Minimum Five years Follow-up.

A retrospective cohort study. To evaluate the outcomes of vertebral body sliding osteotomy (VBSO) with a minimum follow-up of five years and compare the results with those of anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF). VBSO reportedly results in fewer complications, better lordosis restoration, and faster bone union than corpectomy. Although previous studies demonstrate the outcomes of VBSO with follow-up of two years or longer, results in longer term surveillance remain unknown. This study included 128 patients who underwent VBSO (n=38), ACDF (n=62), or ACCF (n=28) as a treatment for cervical myelopathy and was followed up for five years or more. Fusion, subsidence, C0-2 lordosis, C2-7 lordosis, segmental lordosis, C2-7 sagittal vertical axis, surgical complications, and neck pain visual analog scale, Neck Disability Index, and Japanese Orthopedic Association (JOA) scores were assessed. Comparisons between continuous variables in each group were made using independent sample t tests. For nominal variables, the Fisher exact test or the χ 2 test was used. Paired t test was used to analyze the changes in postoperative values compared with preoperative values. The reoperation rate (0.0%) after VBSO was significantly lower than that after ACCF (14.3%; P =0.028). VBSO had a higher fusion rate at six-month and one-year follow-up, but the fusion rate at five years (97.4%) was not significantly different from that of ACDF (85.5%; P =0.054) and ACCF (85.7%; P =0.077). Segmental lordosis at the five-year follow-up was significantly higher in the VBSO group (16.1°) than in the ACDF (11.9°; P =0.002) and ACCF (6.5°; P <0.001) groups. C2-7 lordosis at five-year follow-up was significantly higher in the VBSO group than in the ACCF group ( P =0.017). Neck pain visual analog scale, Neck Disability Index, and JOA scores and the JOA recovery rate did not show significant intergroup differences during the five-year study period. VBSO showed promising long-term results in terms of low revision rate, fast solid union, and effective segmental lordosis restoration when compared with other anterior reconstruction techniques.

Establishing a relationship using CT between facet distraction and clinical outcomes after ACDF

BACKGROUND CONTEXTAnterior cervical discectomy and fusion (ACDF), the gold standard treatment for radiculopathy and myelopathy, has the potential risk of inducing facet-mediated pain through over-distraction. However, the relationship between the clinical outcomes and facet distraction after ACDF remains unclear. PURPOSETo measure facet distraction using computed tomography (CT) and compare the results with the clinical outcomes after ACDF. STUDY DESIGNRetrospective cohort study. PATIENT SAMPLEA consecutive series of patients (n = 144) who underwent a single-level ACDF were included. OUTCOME MEASURESInterfacet distance on preoperative and postoperative lateral cervical radiographs and CT. Visual analog scale for neck pain (VASn), and arm pain (VASa), neck disability index (NDI), the Short Form 36-item health survey (SF-36) were used for clinical outcomes. METHODSEach patient underwent plain radiography of the lateral cervical spine preoperatively, immediately and two years postsurgery. CT was performed preoperatively, and at 3 days and 1-year postsurgery. The inter-facet distance was measured at each time point, and changes in values from the preoperative distance were noted and used for study. Patient-reported outcome measures were obtained preoperatively and at 2-year follow-up. Receiver operating characteristic (ROC) curves were generated to derive the critical facet distraction point. RESULTSThe 3 weeks postoperative VASn score was the most severe and showed a tendency to decrease during the follow-up period. There was a significant positive correlation between the change value of facet distraction measured using CT and 3 weeks postoperative VASn score. ROC curve analysis showed that the cut-off value of Δ facet distraction was 1.8 mm. The over-distraction group (Δ facet distraction ≥1.8 mm, n = 75) showed significantly worse clinical outcomes than the control group (Δ facet distraction <1.8 mm, n = 69), including neck and arm pain VAS scores at all time points until the final 2-year follow-up. CONCLUSIONThe change value of facet distraction measured using CT rather than plain radiography correlated better with neck pain, and over-distraction contributed to adverse long-term outcomes, including neck and arm pain after ACDF. Additionally, an over-distraction of ≥1.8 mm may cause radiculopathy of adjacent segments along with facet-mediated axial pain; therefore, cage height should be carefully determined to avoid over-distraction during ACDF.

Laminoplasty Versus Laminectomy and Fusion in the Surgery Approach for Multilevel Cervical Spondylotic Myelopathy: A Current Perspective and Meta-Analysis

Background: Cervical spondylotic myelopathy (CSM) is a clinical disease which characterized by degeneration of the intervertebral discs and nearby spinal structures. The goal of this study is to compare laminoplasty (LP) versus laminectomy and fusion (LF) for multilevel cervical spondylotic myelopathy (CSM) in terms of clinical safety and effectiveness. Methods: This study is a meta-analysis from randomized and non-randomized control study. The database being used were PubMed, Google Scholar, Cochrane Registry, and Embase. The authors extensively searched the relevant papers comparing the clinical efficacy and safety of LF and LP for the therapy of multilayer CSM. The outcome measures recorded were visual analog scale (VAS), cervical curvature index (CCI), The Japanese Orthopaedic Association (JOA) scores, Nurich grade, reoperation rate, complications, and rate of nerve palsies. The analysis were performed by using RevMan 5.3. Results: Our meta-analysis includes a total of 14 papers. The pooled mean difference between LF and LP was insignificant in terms of VAS of neck pain (p=0.54), post-operative CCI (p=0.24), JOA score (p=0.29), Nurich grade (p=0.16) and reoperation rate (p=0.21). The complication and nerve palsies rate was higher in LF group compared to LP group (OR 2.60, 95% CI 1.85, 3.64, I2=26%, P &lt; .00001) and (OR 3.18, 95% CI 1.66, 6.11, I2=47%, P=.0005) respectively. Conclusion: Our meta-analysis demonstrates that the majority of clinical outcomes for surgical treatments of multilevel CSM utilizing LF and LP are comparable. However, it was discovered that LP was superior compared to LF in terms of nerve palsy rate. This needs additional validation and research in more extensive sample-size and randomized studies.

Association between Postoperative Neck Pain and Intraoperative Transcranial Motor-Evoked Potential Waveforms of the Trapezius Muscles in Patients with Cervical Myelopathy Who Underwent Cervical Laminoplasty.

Retrospective study. Cervical laminoplasty is safe and effective for treating cervical myelopathy but has a higher frequency of postoperative axial pain compared to other methods. Several studies have reported on the causes of postoperative axial pain, but none have fully elucidated them. This study aimed to investigate the association between postoperative neck pain and intraoperative transcranial motor-evoked potential (MEP) waveforms of the trapezius muscles using transcranial MEPs. Few studies have investigated the association between postoperative neck pain and intraoperative transcranial MEP waveforms of the trapezius muscles in patients with cervical laminoplasty. A total of 79 patients with cervical myelopathy who underwent cervical laminoplasty at our facility between June 2010 and March 2013 were included in this study. Intraoperative control and final waveform were evaluated based on the trapezius muscle MEPs by measuring the latency and amplitude. A neck pain group comprised patients with higher neck pain Visual Analog Scale scores from preoperative value to 1 year postoperatively. The cross-sectional areas of the trapezius muscles and the MEP latencies and amplitudes were compared between patients with and without neck pain. The latency and amplitude of the control waveforms were not significantly different between groups. The neck pain group had a significantly shorter final waveform latency (neck pain: 23.6±2.5, no neck pain: 25.8±4.5; p =0.019) and significantly larger amplitude (neck pain: 2,125±1,077, no neck pain: 1,630±966; p =0.041) than the no neck pain group. Postoperative neck pain was associated with the final waveform latency and amplitude of the trapezius muscle MEPs during cervical laminoplasty. Intraoperative electrophysiological trapezius muscle abnormalities could cause postoperative neck pain.

Efficacy and safety of oblique posterior endplate resection for wider decompression (trumpet-shaped decompression) during anterior cervical discectomy and fusion.

Anterior cervical discectomy and fusion (ACDF) provides a limited workspace, and surgeons often need to access the posterior aspect of the vertebral body to achieve sufficient decompression. Oblique resection of the posterior endplate (trumpet-shaped decompression [TSD]) widens the workspace, enabling removal of lesions behind the vertebral body. This study was conducted to evaluate the efficacy and safety of oblique posterior endplate resection for wider decompression. In this retrospective study, 227 patients who underwent ACDF for the treatment of cervical myelopathy or radiculopathy caused by spondylosis or ossification of the posterior longitudinal ligament and were followed up for ≥ 1 year were included. Patient characteristics, fusion rates, subsidence, and patient-reported outcome measures, including the neck pain visual analog scale (VAS) score, arm pain VAS score, and Neck Disability Index (NDI), were assessed. Patients who underwent TSD during ACDF (TSD group) and those who underwent surgery without TSD (non-TSD group) were compared. Fifty-seven patients (25.1%) were included in the TSD group and 170 patients (74.9%) in the non-TSD group. In the TSD group, 28.2% ± 5.5% of the endplate was resected, and 26.0% ± 6.1% of the region behind the vertebral body could be visualized via the TSD technique. The resection angle was 26.9° ± 5.9°. The fusion rate assessed on the basis of interspinous motion, intragraft bone bridging, and extragraft bone bridging did not significantly differ between the two groups. Furthermore, there were no significant intergroup differences in subsidence. The patient-reported outcome measures at the 1-year follow-up were also not significantly different between the groups. TSD widened the workspace during ACDF, and 26% of the region posterior to the vertebral body could be accessed using this technique. The construct stability was not adversely affected by TSD as demonstrated by the similar fusion and subsidence rates among patients who underwent TSD and those who did not. Therefore, TSD can be safely applied during ACDF when compressive lesions extend behind the vertebral body and are not limited to the disc space, enabling adequate decompression without disrupting the construct stability.

＜Editors' Choice＞ Neck pain after cervical laminoplasty is associated with postoperative atrophy of the trapezius muscle.

Cervical laminoplasty is a safe and effective treatment for cervical myelopathy. However, it has a higher frequency of postoperative axial pain than other methods. A variety of causes of postoperative axial pain have been reported, but these have not been fully elucidated. This study aimed to investigate the association between postoperative axial pain and changes in the posterior neck muscles before and after surgery. The study included 93 patients with cervical myelopathy who underwent surgery at our institute between June 2010 and March 2013. The patients with greater preoperative and 1-year postoperative neck pain visual analog scale scores comprised the neck pain group. The cross-sectional area of the cervical posterior extensor muscles and the trapezius muscle were measured by magnetic resonance imaging before and 1 year after surgery at the C3/4, C4/5, and C5/6 levels to compare with neck pain. The total cross-sectional area atrophy rate (C3/C4, C4/C5, and C5/C6) of the trapezius muscle was significantly larger in patients with neck pain (12.8 ± 13.2) than in those without (6.2 ± 14.4; p<0.05). The cross-sectional area atrophy rate of the trapezius muscle at only the C5/6 level was significantly higher in patients with neck pain (16.7 ± 11.7) compared to those without (3.3 ± 14.4; p<0.001). No significant differences were found in the cross-sectional areas of the cervical posterior extensor muscles. Trapezius atrophy, especially at the lower cervical vertebrae, was associated with neck pain after cervical laminoplasty.

Is disc height loss at 1 year predictive of pseudarthrosis and patient-reported outcome measures following anterior cervical discectomy and fusion with structural allograft?

The authors sought to determine if postoperative disc height loss is associated with pseudarthrosis following anterior cervical discectomy and fusion (ACDF). They also sought to determine if the amount of postoperative disc height loss is predictive of need for revision for pseudarthrosis, as well as the impact of postoperative disc height loss on patient-reported outcome measures (PROMs) following surgery. The authors retrospectively identified patients aged > 18 years who underwent primary one- to three-level ACDF with allograft at a single institution with 1-year postoperative lateral and flexion-extension cervical spine radiographs. Logistic regression models and receiver operating characteristic curves were used for analysis. Alpha was set at p < 0.05. Anterior or posterior disc height loss ≥ 2 mm was found in 52.5% of patients. Patients with a loss ≥ 2 mm were more likely to develop pseudarthrosis (p = 0.021) but not to undergo revision surgery due to pseudarthrosis (p = 0.459). Multivariable analysis identified male sex (OR 1.66, p = 0.013), the number of levels fused (OR 2.09, p < 0.001), and fusion at C6-7 (OR 1.52, p = 0.043) as predictors of disc height loss. The analysis also revealed that levels at the top (OR 0.383, 95% CI 0.170-0.854, p = 0.020) and middle (OR 0.174, 95% CI 0.053-0.548, p = 0.003) of fusion constructs were significant independent predictors of lower pseudarthrosis rates while disc height loss was not. Patients with disc height loss had significantly less improvement in scores for the Neck Disability Index (p = 0.002), visual analog scale (VAS) for arm pain (p = 0.018), and VAS for neck pain (p = 0.011) at 1 year following surgery. This study is, to the authors' knowledge, the largest study to date to assess the impact of postoperative disc height loss after ACDF. Disc height loss following ACDF was not predictive of revision surgery for pseudarthrosis or overall pseudarthrosis rates. However, pseudarthrosis was less likely to occur at the top and middle of fusion constructs. Loss in disc height postoperatively was significantly associated with less improvement in PROMs.

Clinical significance of the C2 slope after multilevel cervical spine fusion.

The C2 slope (C2S) is one of the parameters that can determine cervical sagittal alignment, but its clinical significance is relatively unexplored. This study aimed to evaluate the clinical significance of the C2S after multilevel cervical spine fusion. A total of 111 patients who underwent multilevel cervical spine fusion were included in this study. The C2S, cervical sagittal vertical axis (cSVA), C2-7 lordosis, and T1 slope (T1S) were measured in standing lateral cervical spine radiographs preoperatively and 2 years after the surgery. Clinical outcome measures were visual analog scale (VAS) neck and arm pain scores, Neck Disability Index (NDI), Japanese Orthopaedic Association (JOA) scale score, and patient-reported subjective improvement rate (IR) percentage. Statistical analysis was performed using a paired-samples t-test and Pearson's correlation, and a receiver operating characteristic (ROC) curve to determine the cutoff values of C2S. C2S demonstrated a significant correlation with the cSVA, C2-7 lordosis, T1S, and T1S minus cervical lordosis. C2S revealed a significant correlation with the JOA, neck pain VAS, and NDI scores at 2 years after surgery. Change in the C2S correlated with postoperative neck pain and NDI scores. ROC curves demonstrated the cutoff values of C2S as 18.8°, 22.25°, and 25.35°, according to a cSVA of 40 mm, severe disability expressed by NDI, and severe myelopathy, respectively. C2S can be an additional cervical sagittal alignment parameter that can be a useful prognostic factor after multilevel cervical spine fusion.

Transcorporeal decompression using a fully-endoscopic anterior cervical approach to treat cervical spondylotic myelopathy: surgical design and clinical application

BackgroundAnterior cervical discectomy and fusion (ACDF) is a common procedure for treating cervical spondylotic myelopathy (CSM), however, ACDF may cause pseudoarthrosis, accelerated degeneration of adjacent segments, loss of activity of fused segments and other complications. The full-endoscopic technique can treat CSM, without the aforementioned complications above. Therefore, it is of great clinical value to investigate the surgical scheme of anterior percutaneous full-endoscopic transcorporeal decompression of the spinal cord (APFETDSC).MethodsA total of 28 cases with single-segment Cervical spondylotic myelopathy (CSM) from April 2017 to July 2019 were involved in this study. The size of the disc-osteophyte complex was measured using imaging data prior to the operation. The diameter and direction of the bony passage was determined according to the size and central position of the complex, respectively. Twenty-eight patients underwent the above scheme for CSM. The clinical outcome evaluations included Visual Analog Scale (VAS) scores, Japanese Orthopedic Association (JOA) scores. The imaging assessment included MRI, CT and X-rays.ResultsThe diameter of the designed bony passage was about 6.9 mm, and directed toward the lower edge of the diseased lower vertebral body oblique to the center of the disc-osteophyte complex. All patients successfully completed the operation. The postoperative neck pain VAS and JOA were significantly improved compared to preoperative values (p < 0.01). Postoperative MRI indicated complete decompression of the spinal cord. CT scanning 1 year after the operation revealed an almost healed bony passage and X-ray imaging showed satisfactory physiological curvature of the cervical spine, without cervical instability.ConclusionBased on the diameter and direction of the bony passage, as determined by the size and position of the disc-osteophyte complex, indicated by MRI and CT scanning, anterior percutaneous full-endoscopic transcorporeal decompression of the spinal cord offers good decompression of the spinal cord and ensures excellent therapeutic outcome.

Early Experiences of One-Level Total Disc Replacement (Prestige LP) in Japan: A Comparison of Short-Term Outcomes with Anterior Cervical Discectomy with Fusion.

In Japan, cervical total disc replacement (TDR) was approved in 2017. However, because of its short history, no comparative study between cervical TDR and anterior cervical discectomy with fusion (ACDF) has been conducted in the country. Therefore, we examined and compared the surgical outcomes of TDR and ACDF for one-level cervical degenerative diseases. In total, 50 patients who had received anterior surgeries for one-level cervical degenerative diseases were investigated. Among them, 25 underwent TDR (Prestige LP; Medtronic), whereas the other 25 patients underwent ACDF. ACDF samples were selected from cases conducted before the approval of TDR (-2017.9) and were retrospectively judged to be indicated for TDR. Before and at 1 year after surgery, clinical and radiological outcomes were evaluated. No significant differences in terms of patient demographics between the two groups were observed. A longer operative time was observed in the TDR group than in the ACDF group. Postoperatively, no differences in the Japanese Orthopaedic Association score for cervical myelopathy (C-JOA) score, neck pain visual analog scale, C2-7 angle, and C2-7 range of motion (ROM) were determined. TDR tended to show better neck disability index (NDI) scores postoperatively when compared with ACDF. The local angle at operative level was larger in ACDF. In TDR, the local ROMs were maintained postoperatively; however, in ACDF, the local ROM at the operative level was decreased, and the local ROMs at adjacent levels were increased postoperatively. In the TDR group, although heterotopic ossification was observed in 11 patients (44.0%), and anterior bone loss was identified in 14 patients (56.0%), these issues did not affect surgical outcomes. Conclusively, no differences in terms of C-JOA score and neck pain between patients treated through TDR and ACDF were observed. However, a trend of better NDI scores was identified with TDR. While TDR maintained postoperative ROMs, ACDF showed an increase in the local ROMs at adjacent levels.

A randomized controlled study of two different fixations in anterior cervical discectomy of multilevel cervical spondylotic myelopathy.

Background: To compare the efficacy of anterior cervical discectomy and hybrid fusion (ACDHF) with short-segment plate plus self-locking, stand-alone intervertebral cages versus traditional anterior cervical discectomy and fusion (ACDF) with long-segment plate for multilevel cervical spondylotic myelopathy (MCSM). Methods: All the patients were randomly divided into two groups. 30 cases underwent ACDHF with short-segment plate and self-locking stand-alone cages (hybrid group), while the other 30 cases received ACDF with long-segment plate (control group). In patients meeting the inclusion and exclusion criteria, operation time, blood loss, postoperative drainage volume, length of stay (LOS), visual analogue scale for neck pain (VASNP) scores, Japanese Orthopaedic Association (JOA) score, and the cervical lordosis before and after the operation (5 days, 3, 6, 12 months after operation and final follow-up) were evaluated. The postoperative complications were analyzed as well. Results: All operations were performed uneventfully with followed-up. Compared with ACDF, ACDHF showed a shorter operation time, less intraoperative blood loss and postoperative drainage (p < 0.05). There were no significant difference in LOS between two groups (p ˃ 0.05). Both approaches significantly improved the JOA scores, VASNP scores and the cervical lordosis (p < 0.05). Based on Bazaz grading system, hybrid group had a lower incidence of dysphagia than control group in follow-up periods of 5 days, 3 and 6 months (p < 0.05). Conclusion: ACDF and ACDHF are both effective methods of restoring cervical lordosis following MCSM, but hybrid surgery minimizes intraoperative injury and postoperative dysphagia, making it a viable treatment option for the disorder.

An Algorithmic Posterior Approach to the Treatment of Multilevel Degenerative Cervical Spine Disease: A Multicenter Prospective Study.

The choice of surgical method for the treatment of multilevel degenerative cervical spine disease is based on the assessment of neurological symptoms and anatomical source of compression. However, such decision-making process remains complex and poorly defined. To analyze the effectiveness of an algorithmic posterior approach to the surgical treatment of patients with multilevel degenerative disease of the cervical spine based on the preoperative clinical and imaging parameters. Prospective nonrandomized multicenter cohort study. The study included 338 patients with multilevel degenerative disease of the cervical spine. Two groups of patients were evaluated at 3 neurosurgical centers between 2015 and 2019. The prospective group (Group I, n = 214) consisted of patients who were treated using an algorithm to decide whether they should be treated with an instrumented arthrodesis or a nonfusion procedure. The control group (Group II, n = 124) consisted of patients who underwent posterior decompression with or without stabilization between 2007 and 2014. A total of 192 patients in Group I and 112 in Group II had more than 2 years of follow-up. Visual analog scale (VAS) neck pain, Neck Disability Index (NDI), MacNab and Nurick Scales were collected. Perioperative complications were identified. At 2-year follow-up, Group I had significantly better clinical outcomes based on VAS neck pain score (P = 0.02), NDI score (P = 0.01), satisfaction with surgery on the MacNab Scale (P < 0.001), and outcome of surgery based on the Nurick Scale (P < 0.001). Complication rate was lower in Group I, 5.7% compared with 34.8% in Group II, P = 0.004. The algorithmic posterior approach to the surgical treatment of patients with multilevel degenerative disease of the cervical spine resulted in significant improvement of functional outcomes and a decrease in complications at a minimum 2 years of follow-up.

Age and Gender Based Spinopelvic and Regional Spinal Alignment in Asymptomatic Adult Volunteers: Results of the Multi-Ethnic Alignment Normative Study (MEANS).

Spinal alignment can have a significant impact on a patient's overall quality of life. Predicting the ideal sagittal spinal alignment of a specific individual is still a difficult task. The Multi-Ethnic Alignment Normative Study (MEANS) investigated skeletal alignment, including the spine and lower extremities, of the largest multi-ethnic cohort of asymptomatic adult volunteers. In this analysis, the authors aim to assess normative values of spinopelvic parameters and the regional cervical, thoracic, and lumbar spinal alignment in asymptomatic volunteers stratified by age and sex. Asymptomatic volunteers between ages 18 and 80 years were enrolled prospectively from centers in France, Japan, Singapore, Tunisia, and the United States. Volunteers included reported no significant neck or back pain (Visual Analog Scale ≤2), nor any known spinal disorder(s). All volunteers underwent a standing full-body or full-spine low-dose stereoradiograph. MEANS consisted of 468 volunteers with a mean age of 40.4±14.8 years. Mean cervical lordosis from C2 to C7 was -0.4±12.7°. The T1-slope averaged 23.0±7.9° and showed strong correlation ( r =0.87) with the C7-slope mean of 19.8±8.6°. Thoracic kyphosis (TK) from T4 to T12 showed a mean of 37.4±10.9°. Average L1-S1 lumbar lordosis (LL) was -57.4±11.3°. The mean pelvic incidence (PI) measured 52.0±10.7° and pelvic tilt was 12.5±7.3°. Sacral slope averaged 39.5±8.2°. The average PI-LL was -5.4±10.7°. Approximately 60% of volunteers met the PI-LL criteria within ±10°, 8.3% were ≥10°, while 32.1% were ≤-10°. LL showed moderate correlation with PI ( r =0.53) and TK ( r =0.50), while there was no correlation between TK and PI. Multiple linear regression including PI, TK, and age resulted in the following equation LL=14.6+0.57 (PI)+0.57 (TK)-0.2 (age) ( r =0.75). LL did not change with increasing age in asymptomatic volunteers. However, TK did increase with age leading to an increase in T1-slope and a compensatory increase in cervical lordosis. TK did not correlate with PI and was an independent variable in the prediction of LL. Level II-prospective cohort study.

Full-Endoscopic Anterior Odontoid Screw Fixation: A Novel Surgical Technique.

ObjectiveFirst, to propose a novel minimally invasive technique of full‐endoscopic anterior odontoid fixation (FEAOF) that aims to reduce the risk of retropharyngeal approach (both open and percutaneous techniques) to anterior odontoid screw fixation. Second, to describe steps of the procedure and, lastly, to report the initial outcomes in patients treated with this novel technique.MethodsFour non‐consecutive patients who were diagnosed with a displaced odontoid fracture (Anderson‐D'Alonzo classification type II and Grauer subclassification type A or B) from 2019 to 2020 underwent surgical fixation by our novel technique for anterior odontoid screw fixation. A detailed technical approach of FEAOF for the surgical treatment of type II odontoid fractures was described, and the patients' outcomes based on postoperative radiographic results including computed tomography (CT), clinical outcome parameters including visual analogue scale (VAS) for neck pain both preoperatively and at postoperative follow‐up, and range of neck motion at the final follow‐up were reported.ResultsThe mean age was 33.5 years (24–41), three patients were male. The mean operative time was 93.75 min, and the mean blood loss was 7.5 ml. An immediate post‐operative thin‐sliced CT showed that all patients achieved satisfactory reduction and proper screw position. No screw malposition or penetration was found. At a 6‐month follow‐up, a thin‐sliced CT demonstrated solid bony union in every case. The mean VAS for neck pain was reduced from 6.5 to 0.6 at the 6‐months follow‐up. At the final follow‐up, all patients showed improvement in ranges of motion without any complications; however, one patient was lost to follow‐up.ConclusionsFEAOF is a feasible and effective option for treating type II odontoid fractures. The procedure is less invasive than other techniques and provides clear direct visualization of the involved structures.

Do Inflammatory Cytokines Affect Patient Outcomes After ACDF?

Prospective cohort study. The aim was to determine the relationship between serum inflammatory mediators, preoperative cervical spine disease severity, and clinical outcomes after anterior cervical discectomy and fusion (ACDF). Given the role of the inflammatory cascade in spinal degenerative disease, it has been hypothesized that inflammatory markers may serve as a predictor of patient outcomes after surgery. All patients over age 18 who underwent ACDF for cervical spondylosis with associated radiculopathy and/or myelopathy between 2015 and 2017 from a single institution were prospectively recruited. Preoperative serum inflammatory markers including interleukin (IL)-6, IL-8, tumor necrosis factor-α, high-mobility group box-1 (HMGB1), and white blood cells were measured and correlated to patient demographics, surgical characteristics, duration of symptoms, previous opioid use, and preoperative and 1-year postoperative patient-reported outcomes measures (PROMs) including the neck disability index (NDI), visual analog scale neck pain, visual analog scale arm pain, and Physical and Mental Component Scores of the Short Form-12 (PCS and MCS, respectively) using spearman's rho coefficient. A total of 77 patients were enrolled with follow-up PROMs available for 62% (n=48) of patients at a minimum of 1-year after ACDF. The absolute concentrations of IL-6 and tumor necrosis factor-α were found to be weakly correlated with one another (ρ=0.479). Preoperative symptoms lasting <1-year were weakly correlated with elevation in HMGB1 (ρ=0.421). All other patient demographics exhibited negligible correlation with the preoperative inflammatory markers. Lower preoperative PCS (ρ=0.355) and higher preoperative NDI (ρ=0.336) were weakly correlated with elevated HMGB1. Lower MCS (ρ=0.395) and higher NDI (ρ=0.317) preoperatively were weakly correlated with elevated white blood cells. Postoperative improvement in MCS (ρ=0.306) and MCS recovery ratio (ρ=0.321) exhibited a weakly positive correlation with IL-6. Preoperative cytokine levels demonstrated minimal correlation with preoperative symptoms or clinical improvement, suggesting that profiling of patient cytokines has limited utility in predicting outcomes after ACDF. Level III.

Foraminal Restenosis After Posterior Cervical Foraminotomy for the Treatment of Cervical Radiculopathy.

Retrospective cohort study. To elucidate incidence, risk factor, and clinical effect of bone regrowth after posterior cervical foraminotomy (PCF). Ninety-eight patients who underwent PCF for the treatment of cervical radiculopathy and were followed up for >2 years were retrospectively reviewed. Foraminal dimension, sagittal gap at resected area, facet thickness, lamina length, and cervical range of motion (ROM) were measured. Neck pain visual analogue scale (VAS), arm pain VAS, and neck disability index (NDI) were recorded. Radiographic measures were compared between segments with foraminal narrowing of ≥20% at the 2-years follow-up (restenosis segments) and foraminal narrowing of <20% (patent segments). Sixty-nine patients with 109 segments were included. 73.4% (80/109) of foramens demonstrated foraminal narrowing and decrease of foraminal dimension of ≥20% occurred in 30.3% (30/109). Foraminal dimension at postoperative 2-days was significantly higher in the restenosis segments (P = .047). Furthermore, increase of foraminal dimension was significantly associated with foraminal restenosis of ≥20% (P = .018). Facet thickness was significantly higher in the restenosis segments compared to patent segments at postoperative 2-years follow-up (P = .038). Neck pain VAS was significantly aggravated only in the restenosis group at postoperative 2-years follow-up (P < .001). Foraminal narrowing commonly occurs after PCF due to bone healing. Bone growth occurs in all directions while medial facet growth contributes more to foraminal restenosis. Greater widening of foramen during PCF is a risk factor for postoperative foramen restenosis. Therefore, amount of bone resection should be kept optimal and excessive resection should be avoided to prevent foramen restenosis.