Space Available for Cord,Motion, and disc degeneration at the adjacent segments level of degenerative cervical spondylolisthesis using kinematic MRI

The objective was to evaluate motion, disc degeneration and Space Available for Cord (SAC) at the adjacent segments of degenerative cervical spondylolisthesis (DCS) using kinematic Magnetic Resonance Imaging (kMRI). The cervical spine kMRI of sixty-one DCS spinal levels (38 anterolisthesis and 23 retrolisthesis) were analyzed at the listhesis level and its adjacent segments in three position using kMRI. MRAnalyzer3 was used to analyze translation, angular motion and SAC. The caudad level had significantly less translation motion than the listhesis level in overall DCS or grade 2 anterolisthesis group (P < 0.05). The cephalad level had significant more translational motion than the caudad level in overall DCS or grade 1 retrolisthesis group (P < 0.05). For disc degeneration, the cephalad level had the least disc degeneration and showed significant difference with the listhesis level in overall DCS or overall anterolisthesis or overall retrolisthesis or grade 2 anterolisthesis or grade 1 or 2 retrolisthesis (P < 0.05). For SAC, the listhesis level had the narrowest space in overall DCS groups. In neutral position, grade 1 anterolisthesis had significantly larger SAC at the listhesis and the cephalad level than grade 1 retrolisthesis (P < 0.05). In conclusion, DCS affected cervical spine motion and kinematics. Grade 1 retrolisthesis showed tendency of narrower SAC at the cephalad level more than the same grade anterolisthesis. The likelihood of the adjacent segment disease and spinal cord compression are higher in both grade 2 anterolisthesis and retrolisthesis.     

Risk factors for the development of adjacent segment disease following anterior cervical arthrodesis for degenerative cervical disease: Comparison between fusion methods

This study aimed to determine the risk factors for developing adjacent segment disease (ASDz) after anterior cervical arthrodesis for the treatment of degenerative cervical disease by analyzing patients treated with various fusion methods. We enrolled 242 patients who had undergone anterior cervical fusion for degenerative cervical disease, and had at least 5 years of follow-up. We evaluated the development of ASDz and the rate of revision surgery. To identify the risk factors for ASDz, the sagittal alignment, spinal canal diameter, range of motion of the cervical spine, number of fusion segments, and fusion methods were evaluated. The patients were divided into three groups according to the fusion method: Group A contained patients who had received autogenous bone graft only (53 patients), Group B contained patients who received autogenous bone graft and plate augmentation (62 patients), and Group C contained patients who underwent cage and plate augmentation (127 patients). ASDz occurred in 33 patients, of whom 19 required additional surgery. The risk of developing ASDz was significantly higher in male patients (p = 0.043), patients whose range of motion of the cervical spine was >30° (p = 0.027), and patients with spinal canal stenosis (p = 0.010). The rate of development of ASDz was not different depending on the number of fusion segments. The rate of development of ASDz was 41.5% in Group A, 9.6% in Group B, and 5.51% in Group C (p = 0.03). In patients who underwent anterior cervical arthrodesis for degenerative disease, the occurrence of ASDz was related to age, the cervical spine range of motion, and spinal canal stenosis. Additional plate augmentation for anterior cervical arthrodesis surgery can lower the rate of ASDz development.     

Cervical anterior hybrid technique with bi-level Bryan artificial disc replacement and adjacent segment fusion for cervical myelopathy over three consecutive segments

This study aimed to assess the preliminary clinical efficacy and feasibility of the hybrid technique for multilevel cervical myelopathy. Considering the many shortcomings of traditional treatment methods for multilevel cervical degenerative myelopathy, hybrid surgery (bi-level Bryan artificial disc [Medtronic Sofamor Danek, Memphis, TN, USA] replacement and anterior cervical discectomy and fusion) should be considered. Between March 2006 and November 2012, 108 patients (68 men and 40 women, average age 45 years) underwent hybrid surgery. Based on the Japanese Orthopaedic Association (JOA) score, Neck Disability Index (NDI), and Odom’s criteria, the clinical symptoms and neurological function before and after surgery were evaluated. Mean surgery duration was 90 minutes, with average blood loss of 30 mL. Mean follow-up duration was 36 months. At the final follow-up, the mean JOA (± standard deviation) scores were significantly higher compared with preoperative values (15.08 ± 1.47 versus 9.18 ± 1.22; P < 0.01); meanwhile, NDI values were markedly decreased (12.32 ± 1.03 versus 42.68 ± 1.83; P < 0.01). Using Odom’s criteria, the clinical outcomes were rated as excellent (76 patients), good (22 patients), fair (six patients), and poor (four patients). These findings indicate that the hybrid method provides an effective treatment for cervical myelopathy over three consecutive segments, ensuring a good clinical outcome.     

Effect of posterior subsidence on cervical alignment after anterior cervical corpectomy and reconstruction using titanium mesh cages in degenerative cervical disease

Subsidence after anterior cervical reconstruction using a titanium mesh cage (TMC) has been a matter of debate. The authors investigated and analyzed subsidence and its effect on clinical and radiologic parameters after cervical reconstruction using a TMC for degenerative cervical disease. Thirty consecutive patients with degenerative cervical spine disorders underwent anterior cervical corpectomy followed by reconstruction with TMC. Twenty-four patients underwent a single-level corpectomy, and six patients underwent a two-level corpectomy. Clinical outcomes were assessed using a Visual Analogue Scale (VAS), the Japanese Orthopedic Association (JOA) score and the Neck Disability Index (NDI). Fusion status, anterior and posterior subsidence of the TMC, segmental angle (SA) and cervical sagittal angle (CSA) were assessed by lateral and flexion-extension radiographs of the neck. The mean follow-up period was 27.6 months (range, 24 to 49 months). The VAS, NDI and JOA scores were all significantly improved at the last follow-up. No instances of radiolucency or motion-related pseudoarthrosis were detected on radiographic analysis, yielding a fusion rate of 100%. Subsidence occurred in 28 of 30 patients (93.3%). The average anterior subsidence of the cage was 1.4 ± 0.9 mm, and the average posterior subsidence was 2.9 ± 1.2 mm. The SA and CSA at the final follow-up were significantly increased toward a lordotic angle. Anterior cervical reconstruction using TMC and plating in patients with cervical degenerative disease provides good clinical and radiologic outcomes. Cage subsidence occurred frequently, especially at the posterior part of the cage. Despite the prominent posterior subsidence of the TMC, SA and CSA were improved on final follow-up radiographs, suggesting that posterior subsidence may contribute to cervical lordosis.     

C1 lateral mass screw insertion from the caudal–dorsal to the cranial–ventral direction as an alternate method for C1 fixation: A quantitative anatomical and morphometric evaluation

ObjectC1 lateral mass screw has been widely used for fixation of the upper cervical spine. However, traditional fixation methods are not without complication. Morphometric measurement of an alternative approach is conducted.MethodsThree-dimensional CT scans of the cervical spine obtained in 100 adults were evaluated, and key measurements were determined for screw entry points, trajectories, and screw lengths for placement of a C1 screw via this alternate approach. Additional measures were included to account for relevant anatomic variation, including the size of the dangerous lateral zone of the C1 entry point and depth of the atlantooccipital joint surface. Twenty dried atlantal specimens were evaluated to determine corresponding ex vivo measurements.ResultsThe mean maximum angle of medialization was 20.8° ± 2.8° (right) and 21.1° ± 2.8° (left), as measured in the axial CT images. Sagittal CT images show the mean maximum superior angulation was 24.7° ± 4.3° (right) and 24° ± 4.0° (left), and the mean minimum superior angulation was 13.6° ± 4.4° (right) and 13.6° ± 3.9° (left). The mean screw length within the lateral mass was 21.2 ± 1.9 mm (right) and 21.3 ± 2.0 mm (left). Given an additional 10–15 mm needed for rod adaptation, an ideal screw length of 30–35 mm was determined.ConclusionThe C1 insertion caudally from the C2 nerve root may become an alternate method. Preoperative consideration of the ideal screw insertion point, trajectory, and length are vital for safe and effective surgical intervention.     

Application of a stand-alone anchored spacer in noncontiguous anterior cervical arthrodesis with radiologic analysis of the intermediate segment

The purpose of this study was to describe the clinical features of noncontiguous cervical degenerative disc disease (cDDD), investigate the efficacy and complications of a stand-alone anchored spacer (SAAS) for patients with noncontiguous cDDD, and present radiologic analysis of the intermediate segment (IS) after skip-level fusion. Nineteen consecutive patients with noncontiguous cDDD who underwent skip-level anterior cervical discectomy and fusion (ACDF) with SAAS from January 2010 to December 2012 were enrolled in this study. Clinical outcomes were assessed preoperatively and at 24 months postoperatively using the Japanese Orthopaedic Association score, Neck Disability Index, and Visual Analog Scale. Overall cervical alignment (OCA) of the cervical spine, and the range of motion (ROM), intervertebral disc height (IDH), disc signal intensity and disc protrusion of IS were measured and compared before and after surgery. Clinical outcomes significantly improved compared to preoperative scores. The OCA was corrected and maintained at 24 months postoperatively compared with preoperative values (p < 0.05). There were no significant differences in the ROM and IDH of the IS at each follow-up (p > 0.05). However, decreased signal intensity on T2-weighted MRI was evidenced in three mobile IS at final follow-up (20.0%). Skip-level ACDF with SAAS may be an efficacious option for the treatment of noncontiguous cDDD.     

Spinal motion and intradiscal pressure measurements before and after lumbar spine instrumentation with titanium or PEEK rods

Spinal instrumentation and fusion have been incriminated as contributing to adjacent segment degeneration (ASD). It has been suggested that ASD results from increased range of motion and intradiscal pressure (IDP) adjacent to instrumentation. Posterior dynamic stabilization with polyetheretherketone (PEEK) rods has been proposed as potentially advantageous compared to rigid instrumentation with titanium (Ti) rods in reducing the incidence of ASD. We evaluated segmental motions in the cadaveric spine instrumented with PEEK or Ti rods from L3 to S1, as well as the adjacent segment motions and IDP at L1–2 and L2–3. Human cadaveric spines were potted at T12–L1 and S1–2. Spinal instrumentation from L3–S1 was accomplished using pedicle screws with either PEEK or Ti rods. Specimens were subjected to displacement controlled testing: 15° flexion, 15° extension, 10° lateral bending, and 5° right axial rotation using the MTS machine (MTS, Minneapolis, MN, USA). Intradiscal pressure was measured by placing pressure transducers into the intervertebral disc at L1–2 and L2–3. Spinal motion of L2 relative to L3, and L3 relative to S1 was tracked using a three dimensional motion analysis system. Instrumentation with PEEK and Ti rods was associated with a decrease in L3–S1 motion compared to the intact state that was significant in flexion (p = 0.002), and extension (p = 0.0075). Instrumentation with PEEK and Ti rods was associated with an increase in IDP at L1–2 that was significant in flexion (p = 0.0028). Instrumentation with either PEEK or Ti rods resulted in decreased motion at the instrumented levels while increasing IDP at the adjacent level.     

Tantalum trabecular metal implants in anterior cervical corpectomy and fusion: 2-year prospective analysis

Anterior cervical decompression for two or more cervical spondylotic levels can be performed using either multiple anterior cervical discectomies and fusion or anterior cervical corpectomy and fusion (ACCF). A variety of options for ACCF implants exist but to our knowledge, there is no clinical data for the use of tantalum trabecular metal implants (TTMI) for ACCF. A retrospective review was performed of prospectively collected data for ten patients undergoing ACCF with TTMI between 2011 and 2012. Radiological outcome was assessed by measuring the change in cervical (C) lordosis (fusion Cobb and C2–C7 Cobb), graft subsidence (anterior/posterior, determined by the subsidence of anterior/posterior body height of fused segments; cranial/caudal, determined by the cranial/caudal plate-to-disc distances) and rate of fusion using lateral cervical X-rays of patients at 0, 6, 12 and 24 months post-operatively. The Neck Disability Index (NDI) assessed clinical outcome pre-operatively and at 6, 12 and 24 months post-operatively. Cervical lordosis (Cobb angle of fused segment) was 5.2° (± 4.2°) at 0 months and 6.0° (± 5.7°) at 24 months post-operatively. Graft subsidence was observed to occur at 6 months post-operatively and continued throughout follow-up. Anterior, posterior and caudal subsidence occurred more in the first 12 months post-operatively than in the following 12 months (p < 0.05). Average pre-operative NDI was 45%. Average NDIs were 18%, 13% and 10% at 6, 12 and 24 months post-operatively, respectively. ACCF patients treated with TTMI demonstrated stable cervical lordosis over 2 years of follow-up and 100% fusion rates after 2 years. Measures of subsidence appeared to decrease with time. Patients experienced improved clinical outcomes over the 2-year period.     

Anterior decompression and hybrid reconstruction with titanium mesh cage plus plate and self-locking stand-alone cage for the treatment of three-level cervical spondylotic myelopathy

It has been reported that anterior cervical decompression has good clinical outcomes for the treatment of adjacent three-level cervical spondylotic myelopathy (CSM). However, the application of a long plate in the anterior cervical spine poses substantial risks of soft tissue damage. In this retrospective study, we aimed to analyze the clinical and radiological results of the hybrid construction with titanium mesh cage (TMC) plus plate and self-locking stand-alone cage for treatment of adjacent three-level CSM. A total of 28 consecutive patients with adjacent three-level CSM were treated by anterior decompression and hybrid reconstruction with TMC plus plate and self-locking stand-alone cage. Clinical outcomes, complications, fusion rate and time, cage subsidence and spinal curvature were assessed. The mean follow-up period was 22.8 months. The average operative time was 103 ± 18.5 min, and the average blood loss was 115 ± 13.3 mL. The JOA score and degree of spinal curvature were significantly increased at the final follow-up compared with preoperatively (P < 0.05). Twenty-seven cases finally achieved a solid fusion, and the average time to achieve a solid fusion was 6.2 months. Postoperative complications included one case of cerebrospinal fluid leakage (3.57%), one case of temporary sore throat (3.57%) and two cases of TMC subsidence (7.1%). No dysphagia and hoarseness were observed. Anterior decompression and hybrid reconstruction with TMC plus plate and self-locking stand-alone cage could be used safely and effectively for the treatment of adjacent three-level CSM. It could effectively restore cervical lordosis, reduce the complications related to long plate fixation, and lead to satisfactory outcomes.     

Cervical artificial disc replacement with ProDisc-C: Clinical and radiographic outcomes with long-term follow-up

Cervical artificial disc replacement (ADR) is indicated for the treatment of severe radiculopathy permitting neural decompression and maintenance of motion. We evaluated the clinical and radiographic outcomes in cervical ADR patients using the ProDisc-C device (DePuy Synthes, West Chester, PA, USA) with a 5–9 year follow-up. Data were collected through a prospective registry, with retrospective analysis performed on 24 consecutive patients treated with cervical ADR by a single surgeon. All patients underwent single- or two-level ADR with the ProDisc-C device. Outcome measures included neck and arm pain (visual analogue scale), disability (neck disability index [NDI]), complications and secondary surgery rates. Flexion-extension cervical radiographs were performed to assess range of motion (ROM) of the device and adjacent segment disease (ASD). Average follow-up was 7.7 years. Neck and arm pain improved 60% and 79%, respectively, and NDI had an improvement of 58%. There were no episodes of device migration or subsidence. Mean ROM of the device was 6.4°. Heterotopic ossification was present in seven patients (37%). Radiographic ASD below the device developed in four patients (21%) (one single-level and three two-level ADR). No patient required secondary surgery (repeat operations at the index level or adjacent levels). Fourteen out of 19 patients (74%) were able to return to employment, with a median return to work time of 1.3 months. The ProDisc-C device for cervical ADR is a safe option for patients providing excellent clinical outcomes, satisfactory return to work rates and maintenance of segmental motion despite radiographic evidence of heterotopic ossification and ASD on long-term follow-up.     

Surgical treatment of ossification of the ligamentum flavum associated with dural ossification in the thoracic spine

Between January 2006 and December 2009, dural ossification (DO) was found intraoperatively in 26 of 98 patients with thoracic spinal stenosis due to ossification of the ligamentum flavum (OLF). MRI showed single-level (n = 2), two-level (n = 8) and multilevel (n = 16) areas of low signal intensity in the ligamentum flavum of the thoracic spine. Of the 68 ossified segments in the study population, 11 (16.2%) were located in the upper thoracic spine (T1–T4), nine (13.2%) were located in the midthoracic spine (T5–T8), and 48 (70.6%) were located in the lower thoracic spine (T9–L1). All patients underwent en bloc resection of the areas affected by OLF and DO. All patients underwent posterior decompression; we did not use instrumented fusion to restore the stability of the involved segments after decompression for any patient. The dural defect was not repaired. The neurological status had improved at follow up (22–66 months; mean, 46.7 months) from a preoperative mean Japanese Orthopaedic Association score of 5.46 ± 1.73 points to 8.92 ± 1.38 points at the last follow up (t = 13.87, p < 0.05). The mean values for preoperative and postoperative kyphosis of the involved vertebrae were 6.6 ± 1.5° and 8.2 ± 1.4°, respectively; the mean increase in kyphosis was only 1.7 ± 1.4°. Thus, the surgical techniques discussed in this paper for treatment of OLF associated with DO in the thoracic spine, are effective.     

Changes in constraint of proximal segments effects time to task failure and activity of proximal muscles in knee position-control tasks

ObjectiveMaintenance of a limb position against external load (position-control) fails earlier (time to task failure: TTF) than maintenance of identical force against rigid restraint (force-control). Although possibly explained by physiological differences between contractions, we investigated whether less constraint of movements in other planes and proximal segments (commonly less in position-control tasks) shortens TTF.MethodsSeventeen adults (32 ± 7 years) contracted knee extensor muscles to task failure in a position-control task, with and without constraint of motion in other planes and proximal segments, and a force-control task with constraints. Electromyography of knee extensors, their antagonist and hip muscles was recorded with force/position.ResultsTTF was shorter for position-control without (161 ± 55 s) than with constraint (184 ± 51 s). Despite identical constraint, TTF was shorter in position- than force-control (216 ± 56 s). Muscle activity and position variability at failure was greater without constraint.ConclusionConstraint of motion of proximal segments and other planes increases position-control TTF with less muscle activity and variability. As TTF differed between force- and position-control, despite equivalent constraint, other factors contribute to shorter position-control TTF.SignificanceResults clarify that differences in the TTF between position- and force-control tasks are partly explained by unmatched restriction of motion in other planes and proximal segments.     

Sexual function after cervical spine surgery: Independent predictors of functional impairment

Sexual function (SF) is an important component of patient-focused health related quality of life (HRQoL), but it has not been well studied in spine surgery. This study aims to assess SF after cervical spine surgery and identify predictors of SF. This single-center retrospective study evaluates SF of adults who underwent cervical spine surgery 2007–2012. Predictor variables included demographics, medical/surgical history, operative information, HRQoL measures (Neck Disability Index, SF-12), validated SF surveys [Female Sexual Function Index (FSFI) and Brief Sexual Function Inventory (BSFI) for males], and a study-specific SF questionnaire. 59 patients (31M, 28F; mean age = 56 ± 8.4) had significantly lower SF scores compared to age-matched peers: average BSFI = 2.26 ± 1.22 (vs. 06 ± 0.74), average FSFI = 13.05 ± 11.42 (<26.55 indicating sexual dysfunction). In men, lower mental SF-12 and higher NDI, back pain, and number of operated levels were associated with lower BSFI scores (all p < 0.05). In women, higher total number of medications and pain medications were associated with lower FSFI scores (both p < 0.05). 46% of patients reported difficulty performing a sexual position after surgery that they had previously enjoyed. 39% of men had difficulty on top during intercourse, and 32% of participants reported difficulty performing oral sex. 39% of patients reported worse SF, while only 5% reported an improvement in postoperative SF. Men and women who underwent cervical spine surgery had lower SF scores than age-matched peers, likely attributable to general mental health, regional neck disability, back pain, and medications. A large portion of patients reported subjectively worsened SF after surgery.     

Disc herniation in the thoracolumbar junction treated by minimally invasive transforaminal interbody fusion surgery

Minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF) has demonstrated efficacy in the treatment of lumbar degenerative diseases. Use of this procedure for thoracolumbar junction disc herniation remains challenging. Reports concerning MIS-TLIF at the thoracolumbar junction are rare. Thus, we performed a retrospective analysis of the clinical outcomes of 10 patients with thoracolumbar junction disc herniation treated by MIS-TLIF between December 2007 and October 2010. The purpose of this study was to investigate the efficacy and safety of MIS-TLIF for disc herniation in the thoracolumbar junction. Clinical and radiological data were collected and analyzed. Fusion levels included T12–L1 (two patients), L1–L2 (four patients) and L2–L3 (four patients). Clinical outcome was assessed using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI). The average follow-up period was 39.2 months, with a minimum of 24 months. The mean ± standard error of the mean of the operative time, intraoperative blood loss, and x-ray exposure were 128 ± 36 minutes, 204 ± 35 mL, and 43 ± 12 seconds, respectively. The VAS for back and leg pain decreased significantly postoperatively from 6.4 ± 2.7 to 1.5 ± 0.6 (p < 0.01), and from 7.1 ± 2.4 to 1.3 ± 0.4 (p < 0.01) respectively, as did the ODI from 39.3 ± 11.2 to 16.5 ± 4.7 (p < 0.01). Bone fusion was observed in eight patients. There were no other major complications at last follow-up. MIS-TIF is a safe and effective procedure for disc herniation in the thoracolumbar junction. Occurrence of non-union is relatively high compared to previous findings.     

The value of transcranial motor-evoked potentials and free-running electromyography in surgery for cervical disc herniation

The present study prospectively investigated the value of free-running electromyography (EMG) and transcranial motor-evoked potentials (TcMEP) during anterior cervical microdiscectomy and fusion for cervical disc herniation with radiculopathy. Thirty-eight patients were eligible for inclusion in the study. Pain was assessed using the visual analogue scale (VAS) score. Quality of life results were scored according to Odom’s criteria in the postoperative period. Patients with at least a 41% increase in TcMEP amplitude had an excellent postoperative outcome. When the increase of TcMEP amplitude was ? 11% the patient’s outcome was fair. The VAS score decreased from a preoperative mean value of 6.39 ± 2.16 to a 3-month postoperative value of 2.39 ± 1.17. At 12-month follow-up the mean VAS score was 1.65 ± 0.90. TcMEP and free-running EMG are effective for monitoring the spinal cord during surgery and may hold an additional prognostic role.     

Outcomes of single-level cervical disc arthroplasty versus anterior cervical discectomy and fusion

Several studies have established the short-term safety and efficacy of cervical disc arthroplasty (CDA) as compared to anterior cervical discectomy and fusion (ACDF). However, few single-center comparative trials have been performed, and current studies do not contain large numbers of patients. We retrospectively reviewed all patients from a single military tertiary medical center between August 2008 to August 2012 who underwent single-level CDA or single-level ACDF and compared their clinical outcomes and complications. A total of 259 consecutive patients were included in the study, 171 patients in the CDA group with an average follow-up of 9.8 (±9.9) months and 88 patients in the ACDF group with an average follow-up of 11.8 (±9.6) months. Relief of pre-operative symptoms was 90.1% in the CDA group and 86.4% in the ACDF group with rates of return to full pre-operative activity of 93.0% and 88.6%, respectively. Patients who underwent CDA had a higher rate of persistent posterior neck pain (15.8% versus 12.5%), and patients who underwent ACDF were at risk for symptomatic pseudarthrosis at a rate of 3.4%. Reoperation rates were higher in the ACDF group (5.7% versus 3.5%). To our knowledge, this review is the largest, non-funded, comparison study between single-level CDA and single-level ACDF. This study demonstrates that CDA is a safe and reliable alternative to ACDF in the treatment of cervical radiculopathy and myelopathy resulting from spondylosis and acute disc herniation.     

Pelvic parameters of sagittal balance in extreme lateral interbody fusion for degenerative lumbar disc disease

There is increasing interest in the use of pelvic indices to evaluate sagittal balance and predict outcomes in patients with spinal disease. Conventional posterior lumbar fusion techniques may adversely affect lumbar lordosis and spinal balance. Minimally invasive fusion of the lumbar spine is rapidly becoming a mainstay of treatment of lumbar degenerative disc disease. To our knowledge there are no studies evaluating the effect of extreme lateral interbody fusion (XLIF) on pelvic indices. Hence, our aim was to study the effect of XLIF on pelvic indices related to sagittal balance, and report the results of a prospective longitudinal clinical study and retrospective radiographic analyses of patients undergoing XLIF in a single centre between January 2009 and July 2011. Clinical outcomes are reported for 30 patients and the retrospective analyses of radiographic data is reported for 22 of these patients to assess global and segmental lumbar lordosis and pelvic indices. Effect of XLIF on the correction of scoliotic deformity was assessed in 15 patients in this series. A significant improvement was seen in the visual analogue scale score, the Oswestry Disability Index and the Short Form-36 at 2 months and 6 months (p < 0.0001). The mean pelvic index was 48.6° ± 11.9° (± standard deviation, SD) with corresponding mean sacral slopes and pelvic tilt of 32.0° ± 10.6° (SD) and 18.0° ± 9.5 (SD), respectively. XLIF did not significantly affect sacral slope or pelvic tilt (p > 0.2). Global lumbar lordosis was not affected by XLIF (p > 0.4). XLIF significantly increased segmental lumbar lordosis by 3.3° (p < 0.0001) and significantly decreased the scoliotic Cobb angle by 5.9° (p = 0.01). We found that XLIF improved scoliosis and segmental lordosis and was associated with significant clinical improvement in patients with lumbar degenerative disc disease. However, XLIF did not change overall lumbar lordosis or significantly alter pelvic indices associated with sagittal balance. Long-term follow-up with a larger cohort will be required to further evaluate the effects of XLIF on sagittal balance.     

Effects of gastrocnemius fascia lengthening on gait pattern in children with cerebral palsy using the Gait Profile Score

The aim of the present study was to investigate the efficacy of the GPS regarding the quantification of changes in gait following the gastrocnemius fascia lengthening in children with CP. Nineteen children with CP were selected and evaluated in the preoperative period (PRE session) and approximately one year postoperatively (POST session; mean 13.1 ± 5.1 months) using 3D gait analysis and computing the GPS and GVSs. As the GPS represents the difference between the patient's data and the average from the reference dataset, the higher the value of GPS is, more compromised gait of the subject. A statistically significant improvement in mean GPS was found in the POST session (PRE: 13.38 ± 5°; POST: 10.26 ± 2.41°; p < 0.05), with an improvement close to 23%. Moreover, the GVSs demonstrated statistically significant improvements in ankle dorsi-plantarflexion (PRE: 22.20 ± 16.36°; POST: 11.50 ± 6.57°; p < 0.05) and pelvic rotation (PRE: 9.53 ± 3.87°; POST: 6.47 ± 2.98°; p < 0.05). A strong correlation (r = 0.75; p < 0.05) was found between the preoperative GPS and the percentage of GPS improvement. The results demonstrated that the gastrocnemius fascia lengthening produced a global gait pattern improvement, as showed by the GPS value, which decreased after surgery. Besides this, the GVS permitted to better evidence the joints more compromised by the pathology and their improvement due to the surgery, in this case not only the GVS of the ankle joint but also of the pelvis were characterized by higher GVS values.     

A new zero-profile,stand-alone Fidji cervical cage for the treatment of the single and multilevel cervical degenerative disc disease

To investigate the clinical and radiological results of the new zero-profile, stand-alone Fidji cervical cage to treat single- and multiple-level cervical DDD, and evaluate the safety and efficiency. Between October 2011 and July 2014, 72 consecutive patients (41 males and 31 females; mean age 50.9 years [range, 33–68 years]) with cervical DDD who underwent surgery and were followed for more than 2 years were enrolled in this study (mean 31.1 months, range 24–47 months). The study compared clinical outcomes, radiologic parameters and complication rates. The SF-36, VAS, NDI, and JOA scores of all patients were improved significantly after surgery at any time point. (all p < 0.05). The C2–C7 Cobb angle and the disc height index (DHI) of all patients were improved significantly after surgery at any time point (all p < 0.05). From 3 months after surgery to final follow-up the DHI showed a significant reduction comparing 1 week after surgery (all p < 0.05). The fusion rates were 91.7% (66/72) and the radiologic mean fusion time was 9.9 months. Radiological evidence of adjacent segment degeneration (ASD) was observed in 4/41 patients (9.8%). Postoperative complications included epidural hematoma, hoarseness, dysphagia, axial neck pain, and subsidence. The zero-profile, stand-alone Fidji cervical cage for ACDF can be considered an effective, reliable and safe alternative procedure in the treatment of cervical DDD.     

Mazindol in narcolepsy and idiopathic and symptomatic hypersomnia refractory to stimulants: A long-term chart review

ObjectiveMazindol is a tricyclic, anorectic, non-amphetamine stimulant used in narcolepsy and obesity since 1970. This study aimed to evaluate the long-term benefit/risk ratio in drug-resistant hypersomniacs and cataplexy sufferers.MethodsBy retrospective analysis of the patients’ files in the hospitals of Paris-Salpêtrière (n = 91), Montpellier (n = 40) and Lyon (n = 8), the benefit (Epworth Sleepiness Score (ESS), cataplexy frequency, authorization renewal) and tolerance (side-effects, vital signs, electrocardiogram and cardiac echography) of mazindol were assessed.ResultsThe 139 patients (45% men) aged 36 ± 15 years (range: 9–74) suffered narcolepsy (n = 94, 66% with cataplexy), idiopathic (n = 37) and symptomatic hypersomnia (n = 8) refractory to modafinil, methylphenidate and sodium oxybate. Under mazindol (3.4 ± 1.3 mg/day, 1–6 mg) for an average of 30 months, the ESS decreased from 17.7 ± 3.5 to 12.8 ± 5.1, with an average fall of −4.6 ± 4.7 (p < 0.0001) and the frequency of cataplexy fell from 4.6 ± 3.1 to 2 ± 2.8 episodes per week. The cataplexy was eliminated in 14.5% of patients, improved in 27.5%, and unchanged in 29% (missing data in 29%). The treatment was maintained long term in 83 (60%) patients, and stopped because of a lack of efficacy (22%) and/or secondary effects (9%). There was no pulmonary hypertension in the 45 patients who underwent a cardiac echography. The most common adverse effects were dry mouth (13%), palpitations (10%, including one with ventricular hyperexcitability), anorexia (6%), nervousness (6%) and headaches (6%).ConclusionMazindol has a long-term, favorable benefit/risk ratio in 60% of drug-resistant hypersomniacs, including a clear benefit on cataplexy.