A Novel Grading System of Destructive Lumbar Spondyloarthropathy Based on Evaluation of the Facet Joints.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To develop and evaluate a new grading system for destructive lumbar spondyloarthropathy (DLSA) by assessing bony destruction of the facet joints; to evaluate interrater reliability; and to determine the association between anteroposterior (AP) dural sac diameter at the lumbar level and the new grading. SUMMARY OF BACKGROUND DATA: The characteristics of DLSA are unknown, hindering clinical care and research. Imaging to determine the cause of DLSA may positively contribute to patient outcome or well-being by providing prognostic information. PATIENTS AND METHODS: In the magnetic resonance images (MRIs), we measured an axial midline AP dural sac diameter and evaluated bone destruction caused by amyloidosis at the level of the center of each lumbar disk of the lumbar spine. Two orthopedic surgeons independently evaluated each case at two-month intervals and assigned the grade by rating bone destruction at each lumbar level. Weighted κ and intraclass correlation coefficients for interrater reliability were calculated. In addition, the correlation between the AP diameter of the spinal dural sac at the lumbar level and the new MRI-based DLSA grade was examined. RESULTS: The sample size of 82 patients was reached by examining records of 118 consecutive patients. The mean (SD) age of the included patients was 65 (7.2) years, and 36 (43.9%) were women. The grading of DLSA showed moderate to good interrater reliability at both assessments (κ, 0.59-0.78). Intraclass correlation coefficient showed substantial to excellent agreement (intraclass correlation coefficient, 0.63-0.86). The AP diameter of the spinal dural sac at the lumbar level showed a significant correlation with the new grading ( P <0.001). CONCLUSIONS: The new MRI-based grading system for DLSA has good interrater reliability, although the strength of agreement varies somewhat. The new grading system correlates with AP dural sac diameter. Thus, this classification focused on facet erosion, which leads to functional incompetence may be helpful in surgical decision-making.

Effect of Early vs Delayed Surgical Treatment on Motor Recovery in Incomplete Cervical Spinal Cord Injury With Preexisting Cervical Stenosis: A Randomized Clinical Trial.

Importance: The optimal management for acute traumatic cervical spinal cord injury (SCI) is unknown. Objective: To determine whether early surgical decompression results in better motor recovery than delayed surgical treatment in patients with acute traumatic incomplete cervical SCI associated with preexisting canal stenosis but without bone injury. Design, Setting, and Participants: This multicenter randomized clinical trial was conducted in 43 tertiary referral centers in Japan from December 2011 through November 2019. Patients aged 20 to 79 years with motor-incomplete cervical SCI with preexisting canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. Data were analyzed from September to November 2020. Interventions: Patients were randomized to undergo surgical treatment within 24 hours after admission or delayed surgical treatment after at least 2 weeks of conservative treatment. Main Outcomes and Measures: The primary end points were improvement in the mean ASIA motor score, total score of the spinal cord independence measure, and the proportion of patients able to walk independently at 1 year after injury. Results: Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; age range, 41-79 years; 5 [7%] women and 65 [93%] men) were included in the full analysis population (37 patients assigned to early surgical treatment and 33 patients assigned to delayed surgical treatment). Of these, 56 patients (80%) had data available for at least 1 primary outcome at 1 year. There was no significant difference among primary end points for the early surgical treatment group compared with the delayed surgical treatment group (mean [SD] change in ASIA motor score, 53.7 [14.7] vs 48.5 [19.1]; difference, 5.2; 95% CI, -4.2 to 14.5; P = .27; mean [SD] SCIM total score, 77.9 [22.7] vs 71.3 [27.3]; P = .34; able to walk independently, 21 of 30 patients [70.0%] vs 16 of 26 patients [61.5%]; P = .51). A mixed-design analysis of variance revealed a significant difference in the mean change in ASIA motor scores between the groups (F1,49 = 4.80; P = .03). The early surgical treatment group, compared with the delayed surgical treatment group, had greater motor scores than the delayed surgical treatment group at 2 weeks (mean [SD] score, 34.2 [18.8] vs 18.9 [20.9]), 3 months (mean [SD] score, 49.1 [15.1] vs 37.2 [20.9]), and 6 months (mean [SD] score, 51.5 [13.9] vs 41.3 [23.4]) after injury. Adverse events were common in both groups (eg, worsening of paralysis, 6 patients vs 6 patients; death, 3 patients vs 3 patients). Conclusions and Relevance: These findings suggest that among patients with cervical SCI, early surgical treatment produced similar motor regain at 1 year after injury as delayed surgical treatment but showed accelerated recovery within the first 6 months. These exploratory results suggest that early surgical treatment leads to faster neurological recovery, which requires further validation. Trial Registration: ClinicalTrials.gov Identifier: NCT01485458; umin.ac.jp/ctr Identifier: UMIN000006780.

Microendoscope-Assisted Versus Open Posterior Lumbar Interbody Fusion for Lumbar Degenerative Disease: A Multicenter Retrospective Cohort Study.

Background and objectives: Minimally invasive surgery has become popular for posterior lumbar interbody fusion (PLIF). Microendoscope-assisted PLIF (ME-PLIF) utilizes a microendoscope within a tubular retractor for PLIF procedures; however, there are no published reports that compare Microendoscope-assisted to open PLIF. Here we compare the surgical and clinical outcomes of ME-PLIF with those of open PLIF. Materials and Methods: A total of 155 consecutive patients who underwent single-level PLIF were registered prospectively. Of the 149 patients with a complete set of preoperative data, 72 patients underwent ME-PLIF (ME-group), and 77 underwent open PLIF (open-group). Clinical and radiographic findings collected one year after surgery were compared. Results: Of the 149 patients, 57 patients in ME-group and 58 patients in the open-group were available. The ME-PLIF procedure required a significantly shorter operating time and involved less intraoperative blood loss. Three patients in both groups reported dural tears as intraoperative complications. Three patients in ME-group experienced postoperative complications, compared to two patients in the open-group. The fusion rate in ME-group at one year was lower than that in the open group (p = 0.06). The proportion of patients who were satisfied was significantly higher in the ME-group (p = 0.02). Conclusions: ME-PLIF was associated with equivalent post-surgical outcomes and significantly higher rates of patient satisfaction than the traditional open PLIF procedure. However, the fusion rate after ME-PLIF tended to be lower than that after the traditional open method.

[Malignant Spinal Cord Compression].

Malignant spinal cord compression(MSCC)is defined as a compression of the spinal cord or cauda equina with neuropathy caused by tumor spreading to the vertebral body. The common symptoms of MSCC are back pain, neck pain, muscle weakness, sensory reduction, bladder and rectal disturbance. The risk of MSCC is relatively high in patients with lung cancer, breast cancer, and prostate cancer. MSCC is one of the oncologic emergencies that requires prompt diagnosis and treatment to preserve and improve neurological function. Evaluation by magnetic resonance imaging(MRI)and computed tomography( CT)are useful for the diagnosis. The prognosis of these patients is often poor at the time of diagnosis of MSCC, thus it is important for deciding the treatment strategy to consider the prognosis and background of the patient in addition to the objective findings including the degree of MSCC and spinal instability. Treatment options consist of medical, surgical, and radiation therapy. We need a multidisciplinary approach because the pathology of MSCC involves multiple departments, such as medical oncology, orthopedics, and radiology. Supportive care including rehabilitation and preventing skeletal related events are also important. The cancer board, in which each physician and multidisciplinary health care professionals regularly have a discussion and review the cases, is required.

Hypoglossal Nerve Palsy as a Cause of Severe Dysphagia along with the Oropharyngeal Stenosis due to Occipitocervical Kyphosis.

Hypoglossal nerve palsy (HNP) is a potential cause of dysphagia. A 66-year-old man presented to our hospital with dysphagia and neck pain. One year prior to his first visit, he had been diagnosed with upper cervical tuberculosis and had undergone posterior C1-2 fixation. The physical examination led to the diagnosis of dysphagia with HNP, and he had severe weight loss. Radiographic examination revealed that the O-C kyphosis had been exacerbated and that the deformity was likely the primary cause of HNP. To restore the swallowing function, O-C fusion surgery was performed. Postoperatively, the patient showed immediate improvement of dysphagia with gradual recovery of hypoglossal nerve function. In the last follow-up evaluation, swallowing function was confirmed with no signs of HNP. Our results indicate that HNP could be more prevalent in cases with severe cervical kyphosis, being underdiagnosed due to the more apparent signs of the oropharyngeal narrowing.

The Incidence, Clinical Features, and a Comparison Between Early and Delayed Onset of Postoperative Spinal Epidural Hematoma.

STUDY DESIGN: A retrospective observational study. OBJECTIVE: To investigate the incidence and clinical features of symptomatic postoperative spinal epidural hematoma (PSEH) with regard to spinal level and to compare early and delayed onset cases. SUMMARY OF BACKGROUND DATA: PSEH is a serious complication of spinal surgeries. The difference in clinical manifestations between early and delayed PSEH remains unclear. METHODS: Patients who underwent spinal surgeries between 1999 and 2013 at our institution, were reviewed through their medical records. For patients with PSEH, the incidence, duration to onset, duration from onset to evacuation, symptoms, recovery rate (American Spinal Injury Association grade), neurological outcomes, comorbidities, and preoperative use of anticoagulant drugs were examined. We next compared patients with early onset PSEH (onset until day 3) versus delayed onset (onset day 4 or later) regarding these clinical factors. RESULTS: Fourteen patients (0.42%, 14/3371) developed symptomatic PSEH. Initial symptoms were observed between 0 and 7 days (mean 2.6 ±â€Š2.4 d) and almost half (43%, 6/14) occurred during the delayed phase (mean 5.0 ±â€Š1.1 d postsurgery). Paralysis was the predominant symptom in patients with cervical and thoracic surgeries (100%, 6/6), whereas severe pain was most frequent in patients with lumbar procedures (63%, 5/8) (P = 0.019). No significant differences were identified between early and delayed groups. Neurological outcome was good in 10 cases, partial in two cases, and poor in two cases. CONCLUSION: The frequency was consistent in every spinal region, and the symptoms due to PSEH were correlated with spinal level. Almost half the cases were diagnosed after a delay (day 4 or later), which supports the necessity to follow up patients with spinal surgeries more carefully for a week or so and to educate patients and comedical staff about the possibility of delayed hematoma disorders in order not to defer timely intervention. LEVEL OF EVIDENCE: 4.

Prevalence and Natural Course of Transverse Ligament of the Atlas Calcification in Asymptomatic Healthy Individuals.

STUDY DESIGN: A retrospective cross-sectional study. OBJECTIVE: The aim of this study was to assess the prevalence and natural course of calcification of the transverse ligament of the atlas (TLA) in healthy subjects and to investigate the relationship between the calcified lesion and clinical factors. SUMMARY OF BACKGROUND DATA: The prevalence and etiology of TLA calcification in healthy individuals remain uncertain. METHODS: We enrolled 1136 participants undergoing computed tomography (CT) scans in their routine medical checkups. The calcified lesion of the TLA was classified into two types: type 1, thin calcifications (<2 mm) and type 2, curvilinear lesions (>2 mm). We evaluated the natural course of the lesion and compared each clinical variable among subjects with and without TLA calcifications after adjusting for age and sex using propensity score matching techniques. RESULTS: TLA calcification was present in 40 participants (3.5%; 31 males and 9 females; mean age, 65.3 years), and the frequency increased with age (P = 0.001). Both types 1 and 2 calcifications were observed in 26 (65%) and 14 cases (35%), with mean ages of 63.0 and 69.4 years (P = 0.033), respectively. Of these, 37 (93%) underwent another medical checkup afterward, and the morphological changes were further assessed. Five cases (14%) showed enlargement [one case (4%) in type 1 vs. four cases (33%) in type 2], whereas six cases (16%) had disappearance or decrease [six cases (24%) in type 1 vs. 0 cases in type 2, which was statistically significant (P = 0.019)]. A one-to-one propensity score matching analysis revealed no significant differences in clinical variables among subjects with and without TLA calcifications. CONCLUSION: The prevalence of the TLA calcification was not rare in normal subjects. Our results suggest that the calcified lesion could be morphologically changed on a yearly basis and may be associated with the normal aging process. LEVEL OF EVIDENCE: 3.

Arachnoid isolation sign: A predictive imaging feature of spinal meningioma on CT-myelogram.

OBJECT: Numerous studies have demonstrated the imaging features to differentiate spinal meningioma and schwannoma. However, diagnosis can be controversial among clinicians. The purpose of our study was to evaluate the diagnostic value of a novel imaging finding of meningioma on CT-myelogram (CTM). PATIENTS AND METHODS: Imaging findings of patients who underwent surgeries for spinal cord tumors between April 2005 to May 2015 were retrospectively reviewed. Our inclusion criteria were as follows: 1) intradural extramedullary tumor, 2) both magnetic resonance imaging (MRI) and CTM were available. The exclusion criterion was a tumor that showed invasion to extradural space. RESULTS: Thirty spinal meningiomas and schwannomas were identified (eight meningiomas and 22 schwannomas). Among these, two meningiomas showed a characteristic imaging phenomenon on CTM: they were diagnosed as intradural tumors on MR imaging while on CTM, they were isolated by the contrast agent in subarachnoidal space from the intact spinal cord. We named this imaging feature, the arachnoid isolation sign (AIS). None of the schwannomas showed this imaging feature. CONCLUSION: We identified a unique imaging feature of spinal meningioma on CTM. The sensitivity and specificity were 25% and 100%, respectively. In the current case, its diagnostic value was the same as the calcification on CT. Although the number is still small, the AIS may be useful to discern a spinal meningioma from schwannoma.

Recurrent Postoperative Spinal Epidural Hematoma in a Patient with Protein S Deficiency.

A 71-year-old man underwent cervical laminectomy and developed two symptomatic epidural hematomas during the acute postoperative period. On both occasions, drain obstruction was the predominant cause. Congenital Protein S deficiency was diagnosed postoperatively. Protein S is a vitamin K-dependent natural anticoagulant and is essential for inhibiting thrombosis in microcirculation. We assume that Protein S deficiency followed by perioperative bed-rest and surgical invasiveness led to severe hypercoagulability and subsequent drain obstruction. The present findings suggest that both bleeding disorders and hypercoagulability are risk factors for postoperative symptomatic epidural hematoma.