A Novel Anterior Cervical X-Shape-Corpectomy and Fusion for Cervical Spinal Stenosis at C4-C6 Level: A Technical Note.

OBJECTIVE: Anterior cervical corpectomy and fusion (ACCF) is employed in patients with localized cervical spinal stenosis (CSS). However, there are some disadvantages such as subsidence of the titanium mesh cage, slow fusion rates, breakage of the plate and screws, and donor-site complications. For patients with small posterior osteophytes, ossified or hypertrophy of the posterior longitudinal ligaments or ligamentum flavum, the range of decompression from the classic anterior cervical discectomy and fusion (ACDF) cannot meet the clinical requirements. However, employing ACCF is controversial. Therefore, it is necessary to seek a novel, safe and effective surgery that can combine the strengths of ACDF and ACCF. Our objective was to describe a novel anterior approach cervical surgery and investigate its clinical outcomes on segmental CSS at the C4-C6 levels 6 months postoperatively. METHODS: A novel anterior cervical X-shape-corpectomy and fusion (ACXF) was performed to correct the CSS. RESULTS: The patient's neurologic function and myodynamia of the extremities were improved significantly 3 and 6 months after surgery with good bony fusion. Neck pain also was relieved. Immediately postoperative and after 6-month images indicated no significant spinal stenosis. The patient's cervical curvature was improved after surgery without significant implant subsidence or loss of adjacent intervertebral height. There were no postoperative complications. CONCLUSIONS: ACXF may be a safe and effective procedure for segmental CSS and an alternative for ACCF, as it has a wide operative field of view, sufficient decompression range, excellent transverse vertebral bony fusion, less internal fixation-related complications, and graft subsidence and no donor-site complications.

Is Cervical Disc Replacement Valuable in 3-Level Hybrid Surgery Compared with 3-Level Anterior Cervical Discectomy and Fusion?

BACKGROUND: Cervical degenerative disc disease is common in clinical practice. Surgery is among the most effective treatments for patients with cervical radiculopathy, myelopathy, or stenosis. Which treatment is the best option for multilevel cervical degenerative disc disease is controversial. Hybrid surgery, combined cervical disc replacement and anterior cervical discectomy and fusion, may be an alternative treatment for multilevel cervical degenerative disc disease. METHODS: Sixty-four patients with 3-level hybrid surgery and 37 patients with 3-level anterior cervical discectomy and fusion were reviewed retrospectively. Clinical outcomes were based on visual analog scale, Neck Disability Index, 36-Item Short Form Survey, and Japanese Orthopaedic Association scores and Japanese Orthopaedic Association recovery rate. Radiologic assessments included range of motion (ROM) of C2-C7 and adjacent level and cervical lordosis of C2-C7. Perioperative parameters, fusion condition, and complications were assessed. RESULTS: There were no statistical differences observed between the 2 groups for Japanese Orthopaedic Association, Neck Disability Index, or visual analog scale scores. The hybrid surgery group had better physical and mental 36-Item Short Form Survey scores than the fusion group at 1-year follow-up (physical component summary: 49.34 vs. 46.70, P = 0.012; mental component summary: 45.67 vs. 43.95, P = 0.004). ROM of C2-C7 and adjacent levels was less compromised in the hybrid group compared with baseline (64.60% vs. 51.34%, P < 0.001). Cervical lordosis was decreased with time in both groups but was acceptable at final follow-up, and both groups showed solid fusion. CONCLUSIONS: Normal ROM and solid fusion were achieved at both arthroplasty and arthrodesis levels. ROM of replacement levels in different locations of the 3-level construct was acceptable.

Effect of Changes in Postoperative Intervertebral Space Height on Clinical and Radiological Outcomes After Cervical Disc Replacement.

BACKGROUND: Narrowing of intervertebral space height (ISH) is an important pathological change in degenerative spinal disease, and ideal intraoperative distraction and postoperative intervertebral space maintenance is one of the most expectant goals pursued by spinal surgeons. The effect of postoperative ISH changing on the clinical and radiological outcomes after cervical disc replacement is not fully understood, however. METHODS: In this study, the height variation and general trend of postoperative ISH in all patients were analyzed. The patients were divided into 3 groups based on the change of postoperative intervertebral space height (ISH)-group A (ISH <2 mm), group B (ISH 2-4 mm), and group C (ISH >4mm)-and the clinical and radiographic results compared among the 3 groups. RESULTS: A total of 120 consecutive patients with symptomatic cervical disc disease were included in this study. The results showed that the mean ISH increased significantly from 0.729 mm before surgery to 1.143 mm at 1 week, then gradually decreased to 1.032 mm at 3 months, 0.980 mm at 6 months, 0.760 mm at one year, and 0.750 mm at the final follow-up. The average postoperative Neck Disability Index (NDI) was 19.73 ± 0.81, 13.74 ± 4.94, 17.19 ± 4.22, respectively, in the 3 groups at 1 year after surgery and the average range of motion (ROM) was 5.44° ± 3.85° in group A, 9.34° ± 4.38° in group B, and 6.51° ± 4.38° in group C. The mean diameter of the intervertebral foramen was 6.54 ± 1.86 mm in group A, 9.63 ± 2.38 mm in group B, and 9.31 ± 1.68 mm in group C. Degeneration at the superiorly adjacent disc level was observed in 13.51% patients in group A, 9.37% in group B, and 21.05% in group C. Degeneration at the inferiorly adjacent level was radiographically identified in 21.62% in group A, 14.06% in group B, and 26.32% in group C. CONCLUSIONS: This study revealed that cervical disc replacement cannot maintain the intervertebral disc height obtained immediately after surgery. There is no obvious correlation between the change in intervertebral space height and clinical efficacy in the early postoperative stage. Nonetheless, the intervertebral disc height may affect the NDI index 1 year after surgery. If the postoperative intervertebral space height change can be maintained at 2-4 mm at 1 year, satisfactory ROM, intervertebral foramen diameter, and relatively low adjacent segment degeneration may be obtained after cervical disc replacement.

Atlantoaxial Dislocation Associated with Type 1 Neurofibromatosis: Case Report and Review of the Literature.

BACKGROUND: Neurofibromatosis type 1 (NF-1) is an autosomal dominant genetic condition in which spinal deformities are commonly involved. However, atlantoaxial dislocation in NF-1 is extremely rare. A review of the English literature has identified only 10 cases in 8 reports. We report a rare case involving NF-1 associated with severe atlantoaxial dislocation. CASE DESCRIPTION: A 22-year-old woman with NF-1 presented with progressive numbness in her left upper and lower extremities and gait difficulty for 2 months. She was treated with skull traction and partial reduction was achieved. Initial surgical strategy was posterior fusion using a screw-rod-wire construct, but significant bleeding was encountered during the surgery. To shorten the procedure time, a single sublaminar wire of the atlas was tied to the spinous process of the axis to accomplish the reduction and fixation. C1-C2 fusion was performed using iliac crest autograft. The patient had significant improvement of neurologic deficit after surgery. Due to relatively poor fixation provided by the wire, she was requested to rest in bed for the first 3 months and to wear a cervical orthosis for the next 3 months. Solid bony fusion was confirmed by radiologic examination at 18-month follow-up. CONCLUSIONS: Atlantoaxial dislocation is a rare complication in NF-1 patients. Surgical reduction combined with fusion is essential for a good outcome. Spine surgeons should also be knowledgeable about the possibility of significant hemorrhage before surgery.

A rare, acute neurologic deterioration associated with the overactive autoimmune response of ankylosing spondylitis after cervical laminoplasty: A case report.

RATIONALE: We report a rare, acute neurological deterioration after cervical laminoplasty due to post-decompression spinal cord edema associated with ankylosing spondylitis in a 52-year old male patient. The patient was diagnosed with cervical spondylotic myelopathy due to ossification of the posterior longitudinal ligament which was complicated by ankylosing spondylitis. A cervical laminoplasty was performed, adversely resulting in paraparesis and loss of tactile sense. An emergency CT scan following the first laminoplasty revealed that the spinal cord compression due to spinal cord swelling and limited-expansion in cervical canal space. The abnormal pathological state of ankylosing spondylitis may have aggravated spinal cord re-perfusion and increased edema after decompression. PATIENT CONCERNS: Paraparesis and loss of tactile sense after the surgery immediately. DIAGNOSES: Acute neurological deterioration after cervical laminoplasty. INTERVENTIONS: A second emergency surgery was performed to remove the C2-C5 laminae. OUTCOMES: Six months later, the patient had experienced slight improvement in neurological function. LESSONS: Abnormal spinal cord immune inflammatory reaction associated with ankylosing spondylitis and limited decompression may lead to acute neurological deterioration. The potential overactive inflammatory response following surgery in the patients with autoimmune rheumatoid disease should be carefully considered in spinal surgery. Timely diagnosis and treatment may benefit these patients.

[Modified incision to prevent the postoperative spinal lateral angulation in surgery via anterior approach for lumbar fracture].

OBJECTIVE: To explore a method of modified incision to prevent the postoperative spinal lateral angulation via anterior approach for lumbar fracture. METHODS: A total 40 patients with lumbar fracture from January 2016 to Jun 2017 were internalized in the study. Including 28 males and 12 females, aged from 27 to 68 years with an average of (39.5±14.9) years. Among them, 28 cases caused by high fall, 9 cases by heavy injury, 3 cases by traffic accidents; and 35 fractures were located at L1,4 at L2,1 at L3. All the fractures were type A based on AO classification. According to Frankel classify of spinal cord injury, 5 cases were grade A, 1 case was B, 10 cases were C, 15 cases were D, 9 cases were E. The patients were divided randomly into modified incision groups and routine incision groups. All patients were treated with decompression, internal fixation and titanium mesh supported bone graft fusion via anterior approach. All the internal fixation materials were ANTERIOR (Medtronic Inc). Incision direction and incision plane were improved in modified incision groups. The coronal Cobb angle and the angle between the vertebral screw and the corresponding endplate were analyzed before and after operation. RESULTS: Pre-and post-operative coronal Cobb angles were (1.20±3.26) °, ( 2.16±3.55)° in modified incision groups and(1.22±4.42)°, (3.91±3.78)° in routine incision groups respectively. And there was no statistical difference before operation, and there was statistical difference after operation between two groups(P=0.017). There was no lateral angulation of more than 5 degrees in modified incision group, but there was lateral angulation of 5 to 10 degrees in routine incision group in 6 cases. The incidence of lateral angulation about 5 degrees after operation was significantly different between two groups (P=0.010). There was significant difference in the angle between the proximal two vertebral screws and the corresponding endplate between two groups (P<0.05), but there was no significant difference in the angle between the distal two vertebral screws and the corresponding endplate (P>0.05). CONCLUSIONS: The improvement of incision direction and plane can effectively prevent the postoperative spinal lateral angulation via anterior approach for lumbar fracture.

Posterior distraction reduction and occipitocervical fixation for the treatment of basilar invagination and atlantoaxial dislocation.

OBJECT: To introduce a novel distraction technique for the treatment of basilar invagination (BI) and atlantoaxial dislocation (AAD) via a posterior-only approach. METHODS: Twenty-one consecutive patients with BI and AAD who underwent posterior distraction reduction and occipitocervical fixation between January 2009 and June 2013 were enrolled in the present study. This novel distraction technique included two steps. First, the distraction between the occipitocervical junction of the rod (OCJR) and the occipital screws was performed to achieve horizontal and partial vertical reduction. Secondly, the distraction was performed between the C2 screws and OCJR to achieve complete vertical reduction. The pre- and postoperative JOA score, the extent of reduction, the fusion status, and the complications were recorded and analyzed. RESULTS: The mean follow-up was 18.3 months with a range of 10-32 months. No patient incurred neurovascular injury during surgery. The mean JOA score at the last follow-up (15.4) showed significant improvement (P<0.01) compared with the pre-operative parameters (11.2). Complete horizontal reduction was achieved in 18 patients (85.7%), and complete vertical reduction was achieved in 17 patients (80.9%). The rest patients are all received greater than 50% horizontal and vertical reduction. Solid fusion was achieved in 20 patients (95.2%). Mild dysphagia was observed in two patients. One patient suffered from postoperative fever and pulmonary infection. CONCLUSION: This novel distraction technique may provide satisfactory reduction via a posterior-only approach without exposure of the C1/2 facet joint. Therefore, it is a safe and effective method for the treatment of BI with AAD.