Dorsal instrumentation with and without vertebral body replacement in patients with thoracolumbar osteoporotic fractures shows comparable outcome measures

Purpose

In the surgical treatment of osteoporotic spine fractures, there is no clear recommendation, which treatment is best for the individual patient with vertebra plana and/or neurological deficit requiring instrumentation. The aim of this study was to evaluate clinical and radiological outcomes after dorsal or 360° instrumentation of osteoporotic fractures of the thoracolumbar spine in a cohort of patients representing clinical reality.

Methods

A total of 116 consecutive patients were operated on between 2008 and 2020. Inclusion criteria were osteoporotic fracture, thoracolumbar location, and dorsal instrumentation. In 79 cases, vertebral body replacement (VBR) was performed additionally. Patient outcomes including complications, EQ-5D at follow-up, and sagittal correction were analyzed.

Results

Medical and surgical complications occurred in 59.5% of patients with 360° instrumentation compared to 64.9% of patients with dorsal instrumentation only (p = 0.684). Dorsal instrumentation plus VBR resulted in a sagittal correction of 9.3 ± 7.4° (0.1–31.6°) compared to 6.0 ± 5.6° (0.2–22.8°) after dorsal instrumentation only, respectively (p = 0.0065). EQ-5D was completed by 79 patients after 4.00 ± 2.88 years (0.1–11.8 years) and was 0.56 ± 0.32 (− 0.21–1.00) for VBR compared to 0.56 ± 0.34 (− 0.08–1.00) without VBR after dorsal instrumentation (p = 0.994).

Conclusion

360° instrumentation represents a legitimate surgical technique with no additional morbidity even for the elderly and multimorbid osteoporotic population. Particularly, if sufficient long-term construct stability is in doubt or ventral stenosis is present, there is no need to abstain from additional ventral reinforcement and decompression.

     

Comparison of open and minimally invasive techniques for posterior lumbar instrumentation and fusion after open anterior lumbar interbody fusion

Background contextMinimally invasive techniques for spinal fusion have theoretical advantages for the reduction of iatrogenic injury. Although this topic has been investigated previously for posterior-only interbody surgery, such as transforaminal lumbar interbody fusion, similar studies have not evaluated these techniques after anteroposterior spinal fusion, a study design that can more accurately determine the effect of pedicle screw placement and decompression via a minimally invasive technique without the confounding effect of simultaneous interbody cage placement.PurposeTo compare process measures that provide insight into the morbidity of surgery, such as surgical time and the length of postoperative hospital stay between open and minimally invasive anteroposterior lumbar fusion; and to compare the complications during the intraoperative and early postoperative period between open and minimally invasive anteroposterior lumbar fusion.Study designRetrospective case-control study.Patient sampleOne hundred sixty-two patients.Outcome measuresEstimated blood loss, length of surgery, intraoperative fluoroscopy time, length of postoperative hospital stay, malpositioned instrumentation on postoperative imaging, and postoperative complications, including pulmonary embolus and surgical site infection.MethodsPatients who underwent open anterior lumbar interbody fusion followed by either traditional open posterior fusion (Open group) or minimally invasive posterior fusion (minimally invasive surgery [MIS] group) were matched by the number of surgical levels. A chart review was performed to document the intraoperative and postoperative process measures and associated complications in the two groups. Secondary analyses were performed to compare the subgroups of patients, who did and did not undergo a posterior decompression at the time of posterior instrumentation to determine the effect of decompression.ResultsBaseline characteristics were similar between the Open and MIS groups. Estimated blood loss and postoperative transfusion rate were significantly higher in the Open group, differences that the subanalyses suggested were largely because of those patients who underwent concomitant decompression. Length of stay was not significantly different between the groups but was significantly shorter for MIS patients treated without decompression than for Open patients treated without decompression. Intraoperative fluoroscopy time was significantly longer in the MIS group. There was no difference in the infection or complication rates between the groups.ConclusionsOur case-control study comparing patients who underwent anterior lumbar interbody fusion followed by open posterior instrumentation with those who underwent anterior lumbar interbody fusion followed by minimally invasive posterior instrumentation demonstrated that patients undergoing MIS fusion without decompression had less blood loss, less need for transfusion in the perioperative period, and a shorter hospital stay. In contrast, most outcome measures were similar between MIS and Open groups for patients who underwent decompression.     

The impact of diabetes mellitus on spinal fracture with diffuse idiopathic skeletal hyperostosis: A multicenter retrospective study

BackgroundPatients with diffuse idiopathic skeletal hyperostosis (DISH) are susceptible to spinal column injuries with neurological deterioration. Previous studies indicated that the prevalence of diabetes mellitus (DM) in patients with DISH was higher than that in patients without DISH. This study investigates the impact of DM on surgical outcomes for spinal fractures in patients with DISH.MethodsWe retrospectively evaluated 177 spinal fractures in patients with DISH (132 men and 45 women; mean age, 75 ± 10 years) who underwent surgery from a multicenter database. The subjects were classified into two groups according to the presence of DM. Perioperative complications, neurological status by Frankel grade, mortality rate, and status of surgical site infection (SSI) were compared between the two groups.ResultsDM was present in 28.2% (50/177) of the patients. The proportion of men was significantly higher in the DM group (DM group: 86.0% vs. non-DM group: 70.1%) (p = 0.03). The overall complication rate was 22.0% in the DM group and 19.7% in the non-DM group (p = 0.60). Poisson regression model revealed that SSI was significantly associated with DM (DM group: 10.0% vs. non-DM group: 2.4%, Relative risk: 4.5) (p = 0.048). Change in neurological status, mortality rate, instrumentation failure, and nonunion were similar between both groups. HbA1c and fasting blood glucose level (SSI group: 7.2% ± 1.2%, 201 ± 67 mg/dL vs. non-SSI group: 6.6% ± 1.1%, 167 ± 47 mg/dL) tended to be higher in patients with SSI; however, there was no significant difference.ConclusionsIn spinal fracture in patients with DISH, although DM was an associated factor for SSI with a relative risk of 4.5, DM did not negatively impact neurological recovery. Perioperative glycemic control may be useful for preventing SSI because fasting blood glucose level was high in patients with SSI.     

Results of complete hemivertebra excision followed by circumferential fusion and anterior or posterior instrumentation in patients with type-IA formation defect

To evaluate the results of surgical treatment in patients with unlocked full-segmented hemivertebra treated by excision. Twenty-six patients with a mean age of 12.4±1.7 years were included in the study. The mean duration of follow-up was 47.8±21.9 months. Diagnosis of type-IA hemivertebra was established by clinical, radiological, CT, and MRI evaluation. Preoperatively, patients were randomly allocated into two groups. In the first group, patients underwent anterior hemivertebrectomy initially; this was followed by posterior excision of the hemivertebra, posterior instrumentation, and fusion. In the second group, posterior components of the hemivertebra were excised at first, then the hemivertebra body was excised anteriorly, and this was followed by anterior instrumentation and fusion. For both groups, compression was applied to the convex side while distraction was applied to the concave side. Frontal and sagittal plane analysis of radiograms obtained preoperatively, postoperatively, and after a minimum period of 2 years was performed. The balance was analyzed clinically and radiologically by the measurement of the lateral trunk shift (LT) and shift of head (SH). The mean preoperative and postoperative Cobb angles were 45.5°∓11.4° and 16.8°∓7.9°, respectively, and postoperatively, a mean correction rate of 64.4±13.9% was obtained (P=0.00). The mean correction rate was 61.2±13.3% (19.2°∓7.6°) for the last follow-up visit. Sagittal plane analysis demonstrated either conservation of physiological sagittal contours or a normalizing effect following excision of hemivertebra combined with anterior or posterior instrumentation. When postoperative balance values were compared, a statistically significant correction was found in terms of LT and SH values. Although none of the patients had complete balance (SH: 0 mm) or balanced curves (0 mm<SH<15 mm) preoperatively, 20 (76.9%) of the patients had a balanced trunk after surgical intervention. Circumferential fusion could be achieved in all cases. No neurological complication developed, the only complication was delayed wound healing. In view of these data, it is concluded that these techniques can be safely used for this patient group at low thoracic, thoracolumbar, and lumbar levels of vertebral column with high correction rates.     

Laparoscopic antireflux surgery for the elderly: A surgical and quality-of-life study

Purpose Laparoscopic antireflux surgery (LARS) has long been introduced as an alternative method for the treatment of gastroesophageal reflux disease (GERD) in young adults. However, the safety of this procedure and the associated improvement in the quality of life for the elderly are rarely discussed. This study compared the results between young and elderly patients who underwent laparoscopic fundoplication for the treatment of GERD. Methods From January 1999 to January 2006, there were 231 adult patients who underwent LARS for GERD at a single institute. Among all patients, 33 patients were older than 70 years old (14.3%, 73.0 ± 1.9, range 70–76), 198 patients were younger than 70 years old (85.7%, 46.6 ± 11.5, range 20–69). The clinical characteristics, operation time, postoperative hospital stay, surgical complications, and quality of life were retrospectively analyzed. Results The mean operation time had no significant difference between the younger group and the elderly group. The mean postoperative hospital stay in the elderly group was slightly longer than the younger group (4.1 ± 2.5 days vs 3.4 ± 1.3 days, P = 0.19). There were no mortalities and no major complications found in each group. No patients required conversion to an open procedure. Four patients had minor complications (three in the elderly group, rate: 9.0%; one in the younger group, rate: 0.5%, P < 0.05). There were two patients in the nonelderly group who had recurrence. A comparison of the preoperative and postoperative Gastro-Intestinal Quality of Life Index (GIQLI) scores showed significant improvements (99.3 ± 19.2 points, and 110.2 ± 20.6 points, respectively, P < 0.05) with no significant difference between the two groups. Conclusion Laparoscopic antireflux surgery thus appears to provide an equivalent degree of safety and symptomatic relief for elderly patients with GERD as that observed in young patients.     

A prospective study comparing three different all-posterior surgical techniques in the management of thoracolumbar spinal tuberculosis

BackgroundPosterior only surgery has been widely performed in the treatment of thoracic and lumbar spinal tuberculosis. Surgical options include debridement with posterior instrumentation only or combined with anterior reconstruction. The aim of this study is to investigate and compare the clinical, functional and radiological outcomes using a single-stage posterior only surgery in thoracolumbar spinal tuberculosis by three different surgical techniques.MethodsPatients undergoing posterior only surgery for thoracic and lumbar spinal tuberculosis were followed up prospectively and included. Three different procedures, Group-A: Posterior instrumentation with anterior cage reconstruction (n = 49), Group-B: Posterior instrumentation and anterior autologous bone-grafting (n = 21) and Group-C: Posterior column shortening without anterior-reconstruction (n = 52) were compared for kyphosis correction achieved, kyphosis at final follow-up and degree of correction lost. Neurological assessment was done using ASIA impairment Scale(AIS) grades. Functional assessment was done using Visual analogue score (VAS), Modified McNab criteria and NASS satisfaction score.ResultsA total of 122 patients were included in the study, Group-A (49), Group-B (21) and Group-C (52). Radiological correction of kyphotic deformity in anterior reconstruction, Group-A (20.17 ± 9.25⁰) was higher than 13.97⁰ ± 6.06⁰ and 14.27⁰ ± 6.47⁰ achieved in Groups B and C respectively. There was no significant difference in correction lost amongst the three groups (p-value, 0.76). Surgical duration, blood loss and hospital stay were significantly higher in the anterior reconstruction group (p-value, 0.001). Similarly, no significant difference was noted between the three groups in neurological and functional outcomes at 2 years.ConclusionPosterior only approach is eminently satisfactory for treating Thoracolumbar Spinal Tuberculosis (STB). All three groups had similar functional and neurological outcomes. However there was a better correction of deformity in patients with anterior cage reconstruction.     

Subaxial cervical juxtafacet cysts: single institution surgical experience and literature review

Objectives

Juxtafacet cysts (JFCs) of the subaxial cervical spine are rare causes of neurological deficits. Their imaging characteristics, relationship to segmental instability, and potential for inducing acute symptomatic deterioration have only been described in a few case reports and small case series. The objective of the current study was to review the surgical experience at our center and across the literature to better define these variables.

Methods

A single-institution, multisurgeon series of 12 consecutive patients (mean age 63.4 years, range 52–83 years) harboring 14 JFCs treated across 9 years was retrospectively reviewed. Clinical history, neurological status, preoperative imaging, operative findings, pathology, and postoperative outcomes were obtained from medical records. The mean follow up was 9.2?±?7.8 months. A literature review identified 35 studies with 89 previously reported cases of surgically treated subaxial cervical JFCs.

Results

Consistent with previously reported cases, most JFCs in our series involved the C7/T1 level. Nine patients reported axial neck pain, 12 patients had radicular symptoms, four patients had myelopathy, and one patient experienced rapid neurological decline attributable to cystic hemorrhage. Cyst expansion without hemorrhage caused subacute deterioration in one patient. All patients experienced sensory and/or motor improvement following surgical decompression. Preoperative axial neck pain improved in eight of nine patients (89 %). Seven out of 12 patients (58 %) underwent fusion either at the time of decompression (six patients) or at a delayed timepoint within the follow-up period (one patient). Prior history of cervical instrumentation, hypermobility on dynamic imaging, and other risk factors for segmental instability were more common in our series than in previous reports.

Conclusions

Our findings lead us to advocate for early decompression rather than prolonged conservative treatment, for pre- and postoperative dynamic imaging, and for fusion in selected cases as an initial surgical consideration.     

Posterior only versus combined posterior and anterior approaches in surgical management of lumbosacral tuberculosis with paraspinal abscess in adults

Purpose

To compare single-stage posterior transforaminal lumbar interbody fusion, debridement, posterior instrumentation, and postural drainage (posterior-only surgery) with a combined posterior-anterior surgical approach for treatment of adults with lumbosacral spinal tuberculosis (STB) with paraspinal abscess and to determine the clinical feasibility and effectiveness of posterior-only surgical treatment.

Methods

Thirty-nine patients with lumbosacral STB and paraspinal abscess were treated with one of two surgical procedures in our center from September 2003 to December 2012. Nineteen patients were treated with posterior-only surgery (Group A) and 20 were treated with combined posterior–anterior surgery (Group B). Surgery duration, intraoperative blood loss, length of hospitalization, bony fusion rates, complication rates, neurological status, lumbosacral angle correction, and Kirkaldy-Willis functional outcomes of the two groups were compared.

Results

The average follow-up period was 39.1 ± 12.0 months for Group A and 40.7 ± 12.4 months for Group B. Under the Frankel classification, all patients improved with treatment. STB was completely cured and grafted bones were fused within 5–11 months in all patients. There were no persistent or recurrent infections or obvious differences in radiological results between the groups. The lumbosacral angle was significantly corrected after surgical management, but loss of correction was seen in both groups. The average operative duration, blood loss, length of hospital stay, and postoperative complication rate of Group A were lower than those of Group B.

Conclusions

Posterior-only surgery is feasible and effective, resulting in better clinical outcomes than combined posterior–anterior surgeries, especially in surgical time, blood loss, hospital stay, and complications.     

Long-term outcome of laparoscopic antireflux surgery in the elderly

The aim of this retrospective study was to compare results and five-year surgical outcome of laparoscopic antireflux surgery (LARS) in patients younger than 65 years and elderly patients aged 65 years or older. From January 1992 to December 1998, 2684 patients underwent LARS in 31 surgical units; 369 elderly patients (group 1) were compared with 2315 younger patients (group 2). Elderly patients have a higher American Society of Anesthesiologists score (mean, 2.38 versus 1.98). The conversion rate was higher in group 1 (10.2%, n = 38 versus 6.1%, n = 142), as was the morbidity rate (7.6% in group 1 versus 4.5% in group 2). Mean hospital stay was longer for group 1 (7.6 ± 5.6 days versus 5.9 ± 2.8 days). Functional evaluation was excellent in both groups (91-93%) at 3 months and 2 and 5 years. LARS in the elderly is a safe and efficient procedure. Good results appear to be sustainable in the long term. The study participants are listed at the end of the article.     

加速康复外科理念在脊髓型颈椎病手术中应用的临床研究

目的:评价加速康复外科理念在脊髓型颈椎病手术中的作用。方法 :对2012年1月至2015年12月收治的55例脊髓型颈椎病患者的临床资料进行回顾性分析,男30例,女25例;年龄36~71(45.2±3.2)岁;病程1~12(4.5±1.8)个月。其中有35例患者将加速康复外科理念应用在手术治疗及围手术期管理中(研究组),同期手术治疗的20例患者作为对照组(在手术治疗及围手术期管理中未系统应用加速康复外科理念)。手术方式采用前路颈椎间盘切除减压融合内固定(ACDF)38例,后路行单开门椎管扩大成形减压术(单开门)17例。比较两组患者的术后离床活动时间、住院天数;术前、术后1、7、30 d和术后6、12个月分别以日本骨科协会(JOA)评分和视觉模拟评分(visual analogue score,VAS)评估神经功能和疼痛改善情况。结果:所有患者获得随访,时间12~18(14.3±1.5)个月。两组患者在年龄、性别、手术方式、术前JOA评分、VAS评分等方面比较,差异无统计学意义(P0.05)。研究组患者术后离床活动时间3~8(5.54±1.54)h;术后住院天数3~12(5.62±1.59)d;对照组术后离床活动时间24~48(18.80±4.78)h;术后住院天数为7~17(9.85±1.94)d;两组比较差异有统计学意义(P0.01)。两组术后1、7、30 d的JOA评分、VAS评分比较,差异有统计学意义(P0.01)。两组术后6、12个月的JOA评分和VAS评分比较差异无统计学意义(P0.05)。研究组患者住院和随访期间无神经功能恶化、血肿、切口感染、内固定松动等并发症;对照组出现2例切口浅表感染,经换药2周愈合;但两组比较差异无统计学意义(P0.05)。结论:加速外科康复理念运用于脊髓型颈椎病的手术治疗,能够促进患者早期康复,缩短术后住院时间,提高患者对手术的满意度。     

急性脊髓损伤后手术减压时限的临床研究

目的探讨急性脊髓损伤后在不同时间点行手术减压对患者神经功能恢复的影响。方法回顾2005年1月~2009年12月收治的胸椎骨折合并脊髓不完全损伤的89例,按照手术减压时限分为3组:A组,伤后24 h内手术减压(25例);B组,伤后1～3 d内手术减压(47例);C组,伤后3～7 d内手术减压(17例)。根据ASIA残损分级比较术前和术后1年的神经功能情况,比较3组的神经功能恢复情况,分析不同的减压时间疗效有无统计学差异。结果治疗前3组的ASIA残损分级,差异无统计学意义。治疗后3组ASIA残损分级较治疗前提高,A组高于B组和C组(P<0.05),B组高于C组(P<0.05)。结论脊髓不完全损伤后手术减压可以改善神经功能,且手术越早,神经功能恢复越好。     

Early neurological recovery course after surgical treatment of cervical spondylotic myelopathy: a prospective study with 2-year follow-up using three different functional assessment tests

Purpose

Though surgical decompression is today a common option for treatment of cervical spondylotic myelopathy (CSM), little is known about the exact postoperative early neurological recovery course. The purpose of this study was to analyze the functional recovery, its dynamics, its intensity and its pattern, in the early postoperative period after surgical decompression for CSM.

Methods

A prospective non-controlled observational study was performed from March 2006 to July 2008, and included consecutive patients with CSM who underwent surgical decompression. Functional assessments were done before the operation, at 1 month, 6, 12, 18 and 24 months after surgery using three tests: the Japanese Orthopaedic Association (JOA) test, the nine-hole peg test (9HPT) and the Crockard walking test.

Results

Sixty-seven patients were included (mean age of 61 years). The global JOA score improved after surgery, reaching statistical significance at 1 month (from 11.5 ± 2.6 to 13.6 ± 2.0 points, p = 0.0078), then settling to a plateau till the end of follow-up at 24 months (12.7 ± 2.6 points). The 9HPT and the Crockard test did not show any significant improvement after surgery.

Conclusions

Neurological recovery after surgical decompression has been proved to be very fast during the first month, but stabilizes afterwards. The JOA score is the best assessment to reveal neurological improvement in the early recovery course.     

Surgical options for osteoporotic vertebral compression fractures complicated with spinal deformity and neurologic deficit

IntroductionThis paper describes surgical options for Osteoporotic vertebral compression fracture (OVCF) with acute flexible or chronic rigid kyphosis, and pseudarthrosis complicated with pain and neurologic deficit.MethodsThis study has two components. a) A prospective clinical study of surgical treatment of 31 patients (age: 69 ± 11 years) with either acute flexible or progressive pseudarthrotic kyphosis manifested with severe pain or neurological deficit between 2010 and 2014. Eleven patients exhibited neurocompression (Frankel B, C, D). Surgery consisted in indirect reduction, kyphoplasty, and short posterior instrumentation in 28 patients and multilevel instrumentation in three. b) The second component involved a literature search of OVCF complicated with acute or painful chronic deformities and neurologic deficit, managed with open surgical approach.ResultsIndirect reduction, kyphoplasty and short posterior stabilization can restore satisfactory anatomic alignment and neurological deficit. Multilevel instrumentation was used for rigid long kyphosis. Complications were related to a) screw pull out and junctional kyphosis (4 patients) one of the patients also developed anterior migration of cement, b) cement leakage (4 patients). L5 radiculopathy occurred in one patient. The others remained asymptomatic. The literature review concluded that corpectomy with anterior, posterior or combined instrumentations is indicated for burst fractures, or rigid kyphosis with neurocompression. Prompt decompression with anatomical alignment may restore paraplegia. Complications were germane to osteoporotic bone predisposing to hardware loosening or cut out and dislodgement of instrumentation.DiscussionNeurologic deficit associated with fractures or progressive pseudarthrotic kyphosis effectively may respond to indirect postural reduction, kyphoplasty and posterior percutaneous short segment transpedicle instrumentation. For burst fractures and rigid chronic kyphosis corpectomy reconstructed with cages and anterior, or posterior or combined instrumentations can restore and maintain normal anatomy. The following guidelines for optimal surgical instrumentation have been established: To prevent screw loosening and junctional kyphosis the instrumentation should not end within the kyphotic segment. Screws for anterior instrumentation should penetrate the contralateral cortex. Multiple site of fixation or combined anterior and posterior instrumentations dissipate stresses at any one site. Augmentation of transpedicle screw fixation with cement is a sound technical principle. Cement should inserted in a doughy state with minimal pressure to prevent cement complications.     

经椎板间内镜椎管减压术治疗老年腰椎侧隐窝狭窄症

目的:探讨经皮椎板间入路内镜下椎管减压术治疗老年腰椎侧隐窝狭窄症的效果。方法:老年腰椎侧隐窝狭窄症患者196例,随机分为观察组和对照组各98例,观察组行经皮椎板间入路内镜下椎管减压术治疗,对照组行经皮椎间孔入路内镜下椎管减压术治疗。分别于术前和术后7 d、1个月、3个月采用视觉模拟评分(VAS)法评估下肢疼痛程度,Oswestry功能障碍指数(ODI)评定腰椎功能,采用侧隐窝角评估侧隐窝狭窄程度,依据MacNab标准评定手术效果,并记录手术并发症。结果:2组术后7 d、1个月、3个月VAS评分、ODI评分均低于术前(P0.05),且观察组均低于对照组(P0.05);观察组、对照组术后7 d软性侧隐窝角[(30.53±9.76)°、(27.27±8.39)°]、骨性侧隐窝角[(33.18±10.36)°、31.52±9.85)°]均大于术前[软性侧隐窝角(14.26±7.92)°、(14.51±6.83)°,骨性侧隐窝角(16.63±6.58)°、(17.02±7.73)°](P0.05),且观察组大于对照组(P0.05);术后3个月,观察组优良率(94%)与对照组(89%)比较差异无统计学意义(P0.05);2组均未出现神经根撕裂、永久性神经损伤等严重并发症。结论:相较于经皮椎间孔入路,经皮椎板间入路镜下椎管减压术对减轻老年腰椎侧隐窝狭窄症患者下肢疼痛、改善侧隐窝狭窄及腰椎功能,效果更明显。     

Retrospective comparison of the surgical results for patients with thoracic myelopathy caused by ossification of the posterior longitudinal ligament: Posterior decompression with instrumented spinal fusion versus modified anterior decompression through a posterior approach

BackgroundIn Japan, approximately 75% of patients with thoracic myelopathy caused by ossification of the posterior longitudinal ligament (OPLL) are treated by posterior decompression with instrumented spinal fusion (PDF) because of its efficacy and safety. To achieve more effective decompression of the spinal cord using a posterior approach, anterior decompression through a posterior approach was developed. However, this technique has a high risk of postoperative paralysis. We have added a couple of ingenuities to this procedure (modified Ohtsuka procedure). This study was performed to report the surgical results of our modified Ohtsuka procedure and to compare them with the results of PDF.MethodsThis was a retrospective case series. From 2008 to 2018, we surgically treated 32 patients: 20 patients treated by PDF (PDF group) and 12 patients by our modified Ohtsuka procedure (modified Ohtsuka group) as the initial surgery. All patients were followed up for at least 12 months. The degree of surgical invasion and patients’ neurological condition were assessed.ResultsThe operative duration and intraoperative blood loss indicated no significant differences (PDF vs. Ohtuska: 507 ± 103 vs. 534 ± 99 min, 1022 ± 675 vs. 1160 ± 685 ml, respectively). The preoperative Japanese Orthopaedic Association (JOA) score was 4.5 ± 2.0 in the PDF group and 3.3 ± 1.4 in the modified Ohtsuka group (p < 0.05). However, the latest JOA score and recovery rate were significantly better in the modified Ohtsuka group than in the PDF group (8.9 ± 1.2 vs. 7.4 ± 2.5 and 70.8 ± 17.6% vs. 44.5 ± 40.2%, respectively). Postoperative paralysis did not occur in the modified Ohtsuka group while four patients had it in the PDF group.ConclusionsThe present study clearly indicated the modified Ohtsuka group showed significantly better surgical outcomes than the PDF group with the recovery rate ≥70%.     

Intra-Operative Neurophysiological Monitoring in Patients with Thoracic Spinal Stenosis: Its Feasibility and High-Risk Factors for New Neurological Deficit

Objective

Considering the high risk of postoperative neurological complications for patients with thoracic spinal stenosis (TSS), intra-operative neurophysiological monitoring (IONM) has been used for detecting possible iatrogenic injury timely. However, the IONM waveforms are often unreliable. This article is designed to determine the test performance of somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) during surgical thoracic decompression in patients with TSS, and to investigate the risk factors associated with deteriorated neurologic function at immediate postoperation.

Methods

Patients undergoing posterior spinal fusion from February 2009 to December 2020 were retrospectively reviewed. Patients were divided into the deteriorated neurologic function (DNF) group and the improved/intact neurological function (INF) group based on the postoperative neurological status. Demographic parameters such as gender, age, height, weight, etiology and IONM data were compared between groups. Demographics and IONM data between DNF and INF groups were compared by independent t or nonparametric tests. The incidence of abnormal SEP was analyzed by Chi-square test.

Results

A total of 108 patients (63 males, 45 females) with an average age of 53.5 ± 14.0 years were included. The SEP and MEP records were available in 94 and 98 patients, with the overall success rates being 87.0% and 90.7%, respectively. The sensibilities and specificities were 100% and 88.2% for SEP, 100% and 98.8% for MEP, respectively. There were 17 patients in DNF group and 91 patients in INF group. High weight (79.1 ± 14.6 vs 69.7 ± 15.7 kg, P = 0.024), high inter-side difference of MEP amplitude (899.1 ± 997.5 vs 492.3 ± 512.4 μV, P = 0.013) and high incidence of abnormal SEP (94.1% vs 64.8%, P = 0.024) were observed in the DNF group. Fourteen (82.4%) patients in the DNF group showed improvement in neurological status during follow-up.

Conclusions

The overall success rates were 87.0% for SEP and 90.7% for MEP in patients with TSS.     

Radial Extracorporeal Shockwave Therapy (rESWT) is not superior to “minimal-dose” rESWT for patients with chronic plantar fasciopathy; a double-blinded randomised controlled trial

BackgroundInvestigating outcomes following radial-extra-corporeal-shockwave-therapy (rESWT) in patients with chronic plantar fasciopathyMethodsThis double-blinded RCT in a single NHS Sports medicine clinic recruited 117 patients with chronic plantar fasciopathy randomised equally to either 3 sessions of rESWT or “minimal-dose” respectively. Mean age 51.7 ± 9.6 years, 66 % female, symptom duration: 32.6 ± 30.8 months.Results“Average pain” improved by 50 % at 6-months, (>1/3 at interim time-points). Statistically significant within-group improvements were identified in pain, local function, and “ability” PROMs in both groups. Fewer benefits in activity levels or mood. No between-group differences were seen at the interim or final time-points.Conclusion3 sessions of “recommended-dose” rESWT is non-superior to “minimal-dose” rESWT in patients with chronic plantar fasciopathy. rESWT may be ineffective in the treatment of patients with chronic plantar fasciopathy, “minimal-dose” rESWT may be sufficient for a therapeutic effect, or a greater number of treatment sessions may be required for benefit.Level of evidenceLevel I – Randomised controlled trial     

Treatment strategies and outcome in patients with non-tuberculous spinal epidural abscess--a review of 46 cases.

OBJECTIVES: Spinal epidural abscess (SEA) is a rare disease and its early detection and appropriate treatment is essential to prevent high morbidity and mortality. There are only few single-institution series who report their experiences with the microsurgical management of SEA and treatment strategies are discussed controversially. Within the last 15 years the authors have treated 46 patients with SEA. This comparatively high number of cases encouraged us to review our experiences with SEA focussing on the clinical presentation, microsurgical management and outcome. METHODS: Clinical charts of 46 cases with a spinal epidural abscess treated between 1990 and 2004 were reviewed. There were 30 men and 16 women, the age ranged between 32 and 86 years (mean: 57 years). The clinical mean follow-up was 8.5 months (range: 2-84). The clinical presentation and severity of neurological deficits were measured by the Frankel grading system on admission and on follow-up visit. RESULTS: The abscess was located in the cervical spine in 8, the thoracic spine in 17 and the lumbar spine in 21 patients. On admission 8 patients were in Frankel grade A, 7 in B, 15 in C, 8 in D and 8 in E. During follow-up 1 patient was in Frankel grade A, 1 in B, 5 in C, 13 in D and 24 in E. 37 patients underwent primary microsurgery with abscess drainage or removal of chronic granulomatous tissue. The clinical symptoms in 4 patients worsened shortly after the operation due to a compression fracture of the vertebral body (n=2) or progress of the abscess (n=2) making re-operation necessary. 9 patients with severe critical illness or without neurological deficits had primarily a CT-guided puncture for assessment of the causative organism. 3 of them needed additional surgical therapy within the hospital stay because of a new neurological deficit. All patients were immobilised and treated with antibiotics for at least 6 weeks. The mortality was 6.5%. As for complications we noted septicaemia (n=5), meningitis (n=1) and a transient malresorptive hydrocephalus (n=1). CONCLUSION: Early diagnosis, microsurgical therapy with appropriate antibiotic therapy and careful observation of patients are the keys to successful management of SEA. The goal of surgical treatment is to isolate the causative organism and to perform a decompression at the site of maximal cord compression in cases of neurological deterioration or severe pain. Instrumentation with primary fixation does not seem to be imperative. In cases of post-operative worsening, a fracture of additionally infected bony elements has to be considered and a stabilisation should be discussed on an individual basis.     

后正中入路Quadrant通道下椎管减压复位联合经皮椎弓根螺钉内固定术治疗合并神经损伤的单节段AO分型A3型胸腰段脊柱骨折

目的 比较后正中入路Quadrant通道下椎管减压复位联合经皮椎弓根螺钉内固定术和Wiltse入路椎弓根螺钉内固定联合椎板切除减压术治疗合并神经损伤的单节段AO分型A3型胸腰段脊柱骨折的临床疗效.方法 2017年1月—2020年1月,本院收治单节段AO分型A3型胸腰段脊柱骨折患者67例,其中采用后正中入路Quadrant通道下椎管减压复位联合经皮椎弓根螺钉内固定术治疗32例(Quadrant组),采用Wiltse入路椎弓根螺钉内固定联合椎板切除减压术治疗35例(Wiltse组).记录2组患者手术时间、术中出血量、术后住院时间及手术相关并发症情况.术前、术后1 d、术后7 d检验血清肌酸激酶(CK)水平.术前、术后3个月及术后12个月测量2组患者伤椎前缘高度比、伤椎后缘高度比、局部后凸Cobb角及椎管内骨折块占位比.术前、术后3个月及术后12个月采用疼痛视觉模拟量表(VAS)评分和Oswestry功能障碍指数(ODI)评价疼痛程度及功能状态;术前及术后12个月采用美国脊髓损伤协会(ASIA)分级评估神经功能,采用Goutallier分级评估椎旁肌脂肪浸润程度.结果 所有手术顺利完成,所有患者随访(18.60±6.13)个月.Quadrant组手术时间较Wiltse组长,术后住院时间较Wiltse组短,差异均有统计学意义(P<0.05).术后1 d,Quadrant组血清CK水平低于Wiltse组,差异有统计学意义(P<0.05);术后7 d组间差异无统计学意义(P>0.05).术后2组伤椎前缘高度比、伤椎后缘高度比、局部后凸Cobb角、椎管内骨折块占位比、VAS评分及ODI均较术前显著改善,且Quadrant组改善优于Wiltse组,差异均有统计学意义(P<0.05).术后12个月,2组神经功能ASIA分级和椎旁肌脂肪浸润程度Goutallier分级均较术前显著改善,差异有统计学意义(P<0.05);组间差异无统计学意义(P>0.05).结论 后正中入路Quadrant通道下椎管减压复位联合经皮椎弓根螺钉内固定术治疗合并神经损伤的单节段AO分型A3型胸腰段脊柱骨折的效果与Wiltse入路椎弓根螺钉内固定联合椎板切除减压术相当,且手术创伤更小、术后恢复更快,骨折椎体高度及椎管内有效容积恢复更好.