Classification and prognostic factors of patients with cervical spondylotic myelopathy after surgical treatment: a cluster analysis.

Identifying potential prognostic factors of CSM patients could improve doctors' clinical decision-making ability. The study retrospectively collected the baseline data of population characteristics, clinical symptoms, physical examination, neurological function and quality of life scores of patients with CSM based on the clinical big data research platform. The modified Japanese Orthopedic Association (mJOA) score and SF-36 score from the short-term follow-up data were entered into the cluster analysis to characterize postoperative residual symptoms and quality of life. Four clusters were yielded representing different patterns of residual symptoms and quality of patients' life. Patients in cluster 2 (mJOA RR 55.8%) and cluster 4 (mJOA RR 55.8%) were substantially improved and had better quality of life. The influencing factors for the better prognosis of patients in cluster 2 were young age (50.1 ± 11.8), low incidence of disabling claudication (5.0%) and pathological signs (63.0%), and good preoperative SF36-physiological function score (73.1 ± 24.0) and mJOA socre (13.7 ± 2.8); and in cluster 4 the main influencing factor was low incidence of neck and shoulder pain (11.7%). We preliminarily verified the reliability of the clustering results with the long-term follow-up data and identified the preoperative features that were helpful to predict the prognosis of the patients. This study provided reference and research basis for further study with a larger sample data, extracting more patient features, selecting more follow-up nodes, and improving clustering algorithm.

Predictive Value of Preoperative Short Form-36 Survey Scale for Postoperative Axial Neck Pain in Patients With Degenerative Cervical Myelopathy.

STUDY DESIGN: Prospective observational study. OBJECTIVE: To evaluate the predictive value of the preoperative Short Form-36 survey (SF-36) scale for postoperative axial neck pain (ANP) in patients with degenerative cervical myelopathy (DCM) who underwent anterior cervical decompression and fusion (ACDF) surgery. METHODS: This study enrolled patients with DCM who underwent ACDF surgery at author's Hospital between May 2010 and June 2016. RESULTS: Out of 126 eligible patients, 122 completed the 3-month follow-up and 117 completed the 1-year follow-up. The results showed that the preoperative social functioning (SF) subscale score of the SF-36 scale was significantly lower in patients with moderate-to-severe postoperative ANP than in those with no or mild postoperative ANP at both follow-up timepoints (P < .05). ACDF at C4-5 level resulted in a higher ANP rate than ACDF at C5-6 or C6-7 level, both at 3-month (P = .019) and 1-year (P = .004) follow-up. Multivariate logistic regression analysis confirmed that the preoperative social functioning subscale score was an independent risk factor for moderate-to-severe postoperative ANP at 3 months and 1 year after surgery, and preoperative NRS was an independent risk factor at 1-year follow-up. No other demographic, clinical, or radiographic factors were found to be associated with postoperative ANP severity (P < .05). CONCLUSIONS: Preoperative social functioning subscale score of SF-36 scale might be a favorable predictive tool for postoperative ANP in DCM patients who underwent ACDF surgery.

Evaluation and Comparation of a Novel Surgical Technique and Hemivertebra Resection to the Correction of Congenital Cervical Scoliosis in Lower Cervical and Cervicothoracic Spine.

OBJECTIVE: To report concave-side distraction technique to treat congenital cervical scoliosis in lower cervical and cervicothoracic spine. To evaluate and compare clinical and radiographic results of this procedure with classic hemivertebra resection procedure. METHODS: This study reviewed 29 patients in last 13 years. These patients were divided into convex-side resection group (group R) and concave-side distraction group (group D). Radiographic assessment was based on parameter changes preoperatively, postoperatively and at last follow-up. Demographic data, surgical data and complications were also evaluated and compared between the 2 groups. RESULTS: In group R, mean age was 8.9 ± 3.3 years and follow-up was 46 ± 18 months. Operation time and blood loss averaged 500 ± 100 minutes, 703 ± 367 mL. In group D, mean age was 9.9 ± 2.8 years and follow-up was 34 ± 14 months. Operation time and blood loss averaged 501 ± 112 minutes, 374 ± 181 mL. Structural Cobb angle was corrected from 29.4° ± 12.5° to 5.3° (2.1°-18.1°) (p = 0.001) and 33.7° ± 14.1° to 12.8° ± 11.4° (p < 0.001) in groups R and D. Compensatory Cobb angle had a spontaneous correction rate of 59.6% (40.0%-80.8%) and 59.7% ± 23.0% in groups R and D. Mandibular incline, clavicle angle and spine coronal balance were significantly improved at last follow-up in both groups. All correction rates were not statistically different between groups. However, group D had significant less blood loss (p < 0.001) and operation time (p = 0.004) per vertebra than group R. Seven patients developed C5 nerve root palsy and recovered by 6 months of follow-up. CONCLUSION: Both surgical procedures are safe and effective in correcting congenital cervical scoliosis. But concave-side distraction technique has less blood loss and time-consuming during surgery, which provides a better option for the treatment of congenital cervical scoliosis.

The application of artificial intelligence in spine surgery.

Due to its obvious advantages in processing big data and image information, the combination of artificial intelligence and medical care may profoundly change medical practice and promote the gradual transition from traditional clinical care to precision medicine mode. In this artical, we reviewed the relevant literatures and found that artificial intelligence was widely used in spine surgery. The application scenarios included etiology, diagnosis, treatment, postoperative prognosis and decision support systems of spinal diseases. The shift to artificial intelligence model in medicine constantly improved the level of doctors' diagnosis and treatment and the development of orthopedics.

Prevalence and Risk Factors of Surgical Treatment for Klippel-Feil Syndrome.

Background: Recently, there have been some reports on surgical treatment for Klippel-Feil syndrome, but the prevalence and risk factors of surgery have not been well evaluated. This study sought to find the prevalence and potential risk factors of surgical treatment. Methods: A retrospective radiographic review of 718 Klippel-Feil syndrome patients seen at Peking University Third Hospital from January 2010 to October 2017 was performed. Parameters included age, gender, deformity, cervical instability, Samartzis classification, and surgical treatment. Based on the surgical treatment they received, patients were divided into a surgery group and a non-surgery group. Prevalence and possible risk factors of surgical treatment were assessed. Results: A total of 718 Klippel-Feil syndrome patients, including 327 men and 391 women, with an average age of 46.8 years were enrolled. According to the Samartzis classification scheme, 621 cases (86.5%) were classified as type I, 48 cases (6.7%) were classified as type II, and 49 cases (6.8%) were classified as type III, respectively. The most commonly fused segments were C2-3 (54.9%) and C5-6 (9.3%). Of all 718 patients, 133 (18.5%) patients underwent surgical treatment, mainly via the posterior approach (69.9%). The clinical factors included age, gender, deformity, instability, and Samartzis classification. Men were more likely to require surgical treatment (p < 0.001). Patients with instability (p < 0.001) or patients with deformity (p = 0.004) were also more likely to undergo surgery. All three of these variables were included in the binary regression analysis. Finally, gender (p < 0.001) and unstable joints (p < 0.001) were identified to be independently associated with surgical treatment. Gender was the most important risk factor with men being 2.39 times more likely to have surgical treatment, while patients with instability were 2.31 times more likely to receive surgery. Conclusion: The prevalence of patients with Klippel-Feil syndrome requiring surgery was 18.5%, with the majority undergoing posterior cervical surgery. Gender and instability were indemnified as independent risk factors leading to surgical treatment.

Single-level Cervical Arthroplasty with Prodisc-C Vivo Artificial Disc: Five-year Follow-up Results From One Center.

STUDY DESIGN: Retrospective study. OBJECTIVE: The aim of this study was to evaluate the long-term clinical and radiographic outcomes of cervical arthroplasty using the ProDisc-C Vivo prosthesis. SUMMARY OF BACKGROUND DATA: Previous reports have shown that cervical arthroplasty with ProDisc-C artificial disc has acceptable clinical outcomes at 5-year and 10-year follow-ups. METHODS: Clinical and radiographic evaluations, including dynamic flexion-extension lateral images, were performed at baseline and at the 5-year follow-up. RESULTS: Twenty-eight patients who underwent single-level ProDisc-C Vivo arthroplasty were followed-up for a mean period of 65 months. The range of motion at the operated level was 8.9°â€Š±â€Š2.3° at baseline and 8.3°â€Š±â€Š4.8° at the final follow-up (P  = 0.494). Fourteen of 28 levels (50%) developed heterotopic ossification (HO). According to McAfee's classification, one level was classified as grade I, nine levels as grade II, two levels as grade III, and two levels as grade IV. Only four of 28 levels (14.3%) had severe HO. Among patients with cervical spondylotic myelopathy, mJOA score was 13.9 ±â€Š2.5° at baseline and 15.9°â€Š±â€Š1.0° at the final follow-up (P  = 0.001 < 0.05). Among patients with cervical spondylotic radiculopathy, Visual Analog Scale (VAS) neck and shoulder was 5.4 ±â€Š1.4° at baseline and 0.7°â€Š±â€Š1.2° at the final follow-up (p = 0.000 < 0.05), VAS arm was 5.1 ±â€Š2.8° at baseline and 0.5°â€Š±â€Š1.2° at the final follow-up (P  = 0.000 < 0.05). A total of 49 adjacent segments were observed and 13 (26.5%) had adjacent segment degeneration. No patient developed recurrent cervical radiculopathy or myelopathy due to adjacent segment disease. No patient underwent re-operation. CONCLUSION: ProDisc-C Vivo arthroplasty had satisfactory clinical and radiographic outcomes at 5-year follow-up.Level of Evidence: 4.

Vertebral Artery Variation in Patients With Congenital Cervical Scoliosis: An Anatomical Study Based on Radiological Findings.

STUDY DESIGN: Observational, anatomical, radiological study. OBJECTIVE: The aim of this study was to explore the incidence and type of vertebral artery (VA) variation in patients with congenital cervical scoliosis and approach their clinical importance during surgery. SUMMARY OF BACKGROUND DATA: Congenital scoliosis of the cervical spine is usually sporadic and caused by a variety of bone structural anomalies. Most of the cases remain asymptomatic. Surgical intervention is the main management for patients with neurological compromise or with cosmetic demands. The operation involved more screw insertion and osteotomy than the regular degenerative cases. The incidence and pattern of VA variants in these patients have not been reported. METHODS: Patients with congenital cervical scoliosis treated in our department were reviewed. We measured Cobb angle of cervical spine. We observed bilateral VAs and recorded variants. We measured their diameter in each segment through CT angiography. The bilateral diameter in each patient was then compared respectively. RESULT: There is a total of 44 patients enrolled. The incidence of VA variation was 41% (18/44). Fifty percent (22/44) of patients had the dominant VA with no difference between concave side and convex side. Patients with a dominant VA had a larger Cobb angle than those who had not (30.25° vs. 23.24°, P < 0.05). The courses of VA were abnormal in 18 patients. Two patients had unilateral variant in V1 segment. Twelve patients had variants in V2 segment. Eight patients had variants in V3 segment. Three patients had VA variants in multiple sites. CONCLUSION: In patients with congenital cervical scoliosis, the dominance of VA is not related to the convex side or concave side, but patients with a dominance of VA have a larger Cobb angle. The incidence of variant in V2 and V3 segment is higher. A thorough evaluation of bilateral VAs is required before surgery. Extra cautions must be taken during surgery.Level of Evidence: 5.

Effect of decompression range on decompression limit of cervical laminoplasty.

BACKGROUNDS: Cervical posterior decompression surgery is used to relieve ventral compression indirectly by incorporating a backward shift of the spinal cord, and this indirect decompression is bound to be limited. This study aimed to determine the decompression limit of posterior surgery and the effect of the decompression range. METHODS: We retrospectively reviewed the data of 129 patients who underwent cervical open-door laminoplasty through 2008 to 2012 and were grouped as follows: C4-C7 (n = 11), C3-C6 (n = 61), C3-C7 (n = 32), and C2-C7 (n = 25). According to the relative location of spinal levels within a decompression range, the type of decompression at a given level was categorized as external decompression (ED; achieved at the levels located immediately external to the decompression range margin), internal decompression (ID; achieved at the levels located immediately internal to the decompression range margin), and central decompression (CD; achieved at the levels located in the center, far from the decompression range margin). The vertebral-cord distance (VCD) was used to evaluate the decompression limit. The C2-C7 angle and VCD on post-operative magnetic resonance images were analyzed and compared between groups. The relationship between VCD and decompression type was analyzed. Moreover, the relationship between the magnitude of the ventral compressive factor and the probability of post-operative residual compression at each level for different decompression ranges was studied. RESULTS: There was no significant kyphosis in cervical curvature (> -5°), and there was no significant difference among the groups (F = 2.091, P = 0.105). The VCD of a specific level depended on the decompression type of the level and followed this pattern: ED < ID < CD (P < 0.05). The decompression type of a level was sometimes affected by the decompression range. For a given magnitude of the ventral compressive factor, the probability of residual compression was lower for the group with the larger VCD at this level. CONCLUSIONS: Our study suggests that the decompression range affected the decompression limit by changing the decompression type of a particular level. For a given cervical spinal level, the decompression limit significantly varied with decompression type as follows: ED < ID < CD. CD provided maximal decompression limit for a given level. A reasonable range of decompression could be determined based on the relationship between the magnitude of the ventral compressive factor and the decompression limits achieved by different decompression ranges.

Evaluation of a combined approach to the correction of congenital cervical or cervicothoracic scoliosis.

BACKGROUND CONTEXT: An anteroposterior combined approach has been used for the treatment of congenital cervical or cervicothoracic scoliosis. However, its outcomes and surgical risks have not been clarified. PURPOSE: We analyzed the characteristics of congenital cervical and cervicothoracic scoliosis and evaluated the outcomes of an anteroposterior combined approach for its treatment. STUDY DESIGN: We carried out a retrospective clinical study of prospectively collected data. PATIENT SAMPLE: Sixteen patients were treated between 2009 and 2013. Their average age was 9.2years. OUTCOME MEASURES: Radiographic and surgical outcomes were measured and recorded. We compared morphological parameters and preoperative and postoperative results. METHODS: All patients underwent surgery with a combined approach. The following radiographic parameters were measured: head tilt (HT), mandible incline (MI), shoulder balance (SB), structural and compensatory curves, cervical lordosis, C7 central sacral vertical line (C7-CSVL) ratio, C7 sagittal vertical axis (C7-SVA) ratio, C2-C7 SVA ratio, the angle between the upper endplate of the T2 vertebra and a horizontal line (T2 tilt), gravity line ratio. Demographic and surgical data were also collected. RESULTS: On average, the duration of follow-up was 68.0 months, surgical blood loss was 675mL, and the duration of surgery was 400.5 minutes. The average correction rate was 64.9% in the structural curve and 29.5% in the compensatory curve. Statistical analysis showed that MI significantly correlated with HT and SB (p<.05). The C7-CSVL ratio correlated with the HT, MI, and SB (p<.05). The C7-SVA ratio correlated with the structural curve and cervical lordosis (p<.05), and the gravity line ratio correlated with the structural and compensatory curve, cervical lordosis, and C7-SVA ratio (p<.05). Moreover, there were correlations between the structural and compensatory curves as well as between the structural curve and cervical lordosis (p<.05). There were significant differences before and after surgery in HT, MI, and structural and compensatory curves. Four patients developed nerve root palsy after surgical correction and totally recovered by 6 months of follow-up. CONCLUSION: The combined approach is an effective surgical option for congenital cervical or cervicothoracic scoliosis. The resection of the hemivertebra cannot only improve head-neck aesthetic appearance but can also maintain the growth potential of the neck.

Delayed epidural pseudoaneurysm following cervical laminectomy and instrumentation in a patient with canal stenosis secondary to skeletal fluorosis: A case report.

RATIONALE: The typical intraoperative presentation of vertebral artery injury (VAI) usually involves profuse bleeding and requires immediate treatment. However, an occult VAI may occur intraoperatively and result in delayed life-threatening epidural pseudoaneurysm several days postoperatively. PATIENT CONCERNS: A 21-year-old man with compressive cervical myelopathy resulting from canal stenosis of skeletal fluorosis underwent decompression of C1 to C7 and instrumentation from C2 to C7. No impressive bleeding event occurred during the operation. On postoperative day 40, progressive quadriplegia developed. DIAGNOSES: Pseudoaneurysm of the VA was established by angiography. INTERVENTIONS: After occlusion of the right VA, the patient underwent hematoma clearing. OUTCOMES: Fortunately, the patient experienced significant recovery of neurologic function after the second surgery. LESSONS: From this case, we realize even in the absence of obvious signs of VAI during a cervical operation, postoperative evaluation should be mandatory for suspected bleeding events occurring at VAI-prone sites during surgery. Moreover, the bone morphological abnormality of skeletal fluorosis was determined to be the most important risk contributing to VAI in this case. The safety limits of bone removal should be determined preoperatively to avoid the effects of bone morphological abnormalities.

Targeted next-generation sequencing reveals multiple deleterious variants in OPLL-associated genes.

Ossification of the posterior longitudinal ligament of the spine (OPLL), which is characterized by ectopic bone formation in the spinal ligaments, can cause spinal-cord compression. To date, at least 11 susceptibility genes have been genetically linked to OPLL. In order to identify potential deleterious alleles in these OPLL-associated genes, we designed a capture array encompassing all coding regions of the target genes for next-generation sequencing (NGS) in a cohort of 55 unrelated patients with OPLL. By bioinformatics analyses, we successfully identified three novel and five extremely rare variants (MAF < 0.005). These variants were predicted to be deleterious by commonly used various algorithms, thereby resulting in missense mutations in four OPLL-associated genes (i.e., COL6A1, COL11A2, FGFR1, and BMP2). Furthermore, potential effects of the patient with p.Q89E of BMP2 were confirmed by a markedly increased BMP2 level in peripheral blood samples. Notably, seven of the variants were found to be associated with the patients with continuous subtype changes by cervical spinal radiological analyses. Taken together, our findings revealed for the first time that deleterious coding variants of the four OPLL-associated genes are potentially pathogenic in the patients with OPLL.

[Evaluation of dysfunction of hand and clinical efficacy in patients with hirayama disease treated with surgery by Jebsen-Taylor Test].

OBJECTIVE: To investigate the clinical efficacy of cervical anterior internal fixation and bone grafting fusion by comparative analyzing hand dysfunction in Hirayama disease patients using Jebsen-Taylor Test (JTT). METHODS: From Feb 2010 to Jan 2014, 20 hirayama disease patients who underwent surgery were enrolled in Department of Orthopaedics, Peking University Third Hospital. JTT were evaluated for the 20 patients before and after surgery. Among them, 9 patients were evaluated before and at three months, one year and more than 2 years after surgery. RESULTS: All sections of the JTT scale indicated that the patients with CSM exhibited a significant impairment compared with healthy adults. Each scale of JTT was improved after surgery in addition to picking up small objects and placing them in a can and simulated feeding. The whole time were improved from 72.3 s to 60.2 s. CONCLUSION: JJT is a valid efficacy evaluation in assessing the impairment of hand and upper extremities of patients with Hirayama disease and the surgery can improve patients' hand function.

Profiles of and correlation between objective and subjective outcome assessments following open-door laminoplasty for cervical spondylotic myelopathy.

BACKGROUND: Open-door laminoplasty is widely used in the treatment of cervical spondylotic myelopathy (CSM). This study aimed to investigate the profiles of and correlation between objective and subjective short-term outcome assessments after open-door laminoplasty for CSM. METHODS: We retrospectively analyzed surgical outcomes in 129 consecutive CSM patients who underwent open-door laminoplasty in Peking University Third Hospital from February 2008 to November 2011. Both objective and subjective assessments were evaluated before surgery, 3 months after surgery, and 1 year after surgery. We then analyzed the profiles of and correlation between objective and subjective short-term outcomes. RESULTS: The Modified Japanese Orthopaedic Association (mJOA) score was significantly improved at 3 months (P < 0.01) and 1 year (P < 0.01) after surgery. Bivariate Logistic regression showed that sensory improvement contributed more to the recovery rate than motor function improvement at 3 months after surgery, while motor function contributed more to the recovery rate at 1 year after surgery. On the subjective assessment (the short form (SF)-36 ), there was no significant improvement at 3 months after surgery (P > 0.05), while physical function (PF), role-physical (RP), and social function (SF) were notably improved at 1 year after surgery (P < 0.01). Improved mJOA score correlated with improvements in PF, RP, bodily pain, general health (GH), vitality (VT), and SF (P < 0.05) at 3 months after surgery; PF, GH, VT, and SF were associated with improved mJOA scores at 1 year after surgery. CONCLUSIONS: Patients benefit from surgery by postoperative restitution of neurological function with early recovery of sensory function, followed by a gradual transition to motor function improvement. At the early stage of recovery, improvement in the mJOA score essentially correlated with improvements in the physical domains of the SF-36, while at the later stage, mJOA score improvement was associated with improvements in both mental and physical domains of the SF-36.

[Measurement and comparison of postoperative anterior cord space between C2-7 and C3-7 laminoplasty on MRI].

OBJECTIVES: To investigate the effect of C(2-7) laminoplasty on postoperative anterior cord space (ACS) compared with C(3-7) laminoplasty, and to provide evidence for reasonable enlargement of decompression range cephalad. METHODS: Fifty-seven Patients underwent cervical laminoplasty from February 2008 to October 2011 were studied retrospectively, which were divided into two groups by decompression range: Group C(3-7) and Group C(2-7). The pre-and post operative JOA scores,VAS scores of neek and shoulder pain, and cervical alignment were compared in each group. The postoperative ACS at each level from C(2-3) to C(7)-T(1) measured on MRI were compared between the two groups. RESULTS: The postoperative JOA scores increased significantly in both groups. VAS scores and cervical alignment showed no significant difference. ACS at C(2-3) and C(3-4) was 6.13 mm (95%CI: 5.71-6.55) and 6.60 mm (95%CI: 6.10-7.11) respectively in Group C(3-7), which increased 2.5 mm and 2.1 mm respectively in Group C2-7 at the same segment, there was significant difference (P < 0.01). However, there was no significant difference of ACS at C(4-5) and any other caudal levels between the two groups. CONCLUSIONS: Compared with conventional C(3-7) laminoplasty, the extensive decompression cephalad to C(2) leads to larger ACS at C(2-3) and C(3-4). When the mid-sagittal diameter of anterior compression is more than 6.10 mm at C(3-4), C(3-7) laminoplasty may cause insufficient decompression, and enlargement of decompression range cephalad should be considered.

Human umbilical cord mesenchymal stem cells: osteogenesis in vivo as seed cells for bone tissue engineering.

Mesenchymal stem cells (MSCs) are ideal seed cells for bone tissue engineering. However, intrinsic deficiencies exist for the autologous transplantation strategy of constructing artificial bone with MSCs derived from bone marrow of patients. In this study, MSCs-like cells were isolated from human umbilical cords and were expanded in vitro. Flow cytometric analysis revealed that cells from the fourth passage were positive for CD29, CD44, CD71, CD73, CD90, and CD105 whereas they were negative for CD14, CD34, CD45, and CD117. Furthermore, these cells expressed HLA-A, B, C (MHC-I), but not HLA-DP, DQ, DR (MHC-II), or costimulatory molecules such as CD80 and CD86. Following incubation in specific inductive media for 3 weeks, cultured cells were shown to possess potential to differentiate into adipogenic, osteogenic or chondrogenic lineages in vitro. The umbilical cord-derived MSCs (UC-MSCs) were loaded with a biomimetic artificial bone scaffold material before being implanted subcutaneously in the back of Balb/c nude mice for four to twelve weeks. Our results revealed that UC-MSCs loaded with the scaffold displayed capacity of osteogenic differentiation leading to osteogenesis with human origin in vivo. As a readily available source of seed cells for bone tissue engineering, UC-MSCs should have broad application prospects.