Radiological Assessment of the Effects of Anterior Cervical Discectomy and Fusion on Distraction of the Posterior Ligamentum Flavum in Patients with Degenerative Cervical Spines.

BACKGROUND: This study aimed to assess the effects of anterior cervical discectomy and fusion (ACDF) on distraction of the posterior ligamentum flavum (LF) by increasing the intervertebral disc height and positioning a graft in patients with degenerative cervical spine disease. METHODS: Sixty-eight patients with degenerative cervical diseases who underwent single-level ACDF were included in the analysis. The intervertebral disc height, Cobb angle, and transverse thickness of the LF were measured, and magnetic resonance imaging was performed both preoperatively and 6 weeks postoperatively on each patient. Correlation analyses were performed to evaluate the relationships between age, sex, change in intervertebral disc height, Cobb angle, and position of the intervertebral implant according to the postoperative change in LF thickness. The position of the intervertebral implant was categorized as anterior, middle, or posterior. We also evaluated radiological effects according to the implant position. RESULTS: The mean intervertebral disc height increased from 5.88 mm preoperatively to 7.49 mm postoperatively. The Cobb angle was 0.88° preoperatively and 1.43° postoperatively. Age (p = 0.551), sex (p = 0.348), position of cage (p = 0.312), pre- and postoperative intervertebral disc height (p = 0.850, p = 0.900), Cobb angle (p = 0.977, p = 0.460), and LF thickness (p = 0.060, p = 1.00) were not related to changes in postoperative LF thickness. Postoperative increase in disc height was related to Cobb angle (r = 0.351, p = 0.038). No other factors were significantly related. The position of the cage was not related with the change of Cobb angle (p = 0.91), LF thickness (p = 0.31), or disc height (p = 0.54). CONCLUSIONS: Change in the intervertebral disc height and the position of the intervertebral implant after ACDF did not affect the thickness of the LF after surgery in patients with degenerative cervical spine disease.

Prognosis of Hardware-Related Problems in Anterior Cervical Discectomy and Fusion with Cage and Plate Constructs.

OBJECTIVE: To analyze hardware-related problems and their prognoses after anterior cervical discectomy and fusion (ACDF) using cages and plates for degenerative and traumatic cervical disc diseases. METHODS: The study included 808 patients who underwent anterior cervical discectomy and fusion for degenerative and traumatic disc diseases with >1 year of follow-up. We investigated time of onset and progression of problems associated with instrumentation and cage usage. The mean follow-up time was 3.4 years. Type of plate, range and level of fusion, patient factors (age, sex, body mass index, and bone mineral density), and local kyphosis were evaluated. RESULTS: Complications were found in 132 cases (16.5%), including subsidence in 69 cases, plate loosening in 8 cases, screw loosening in 8 cases, screw breakage in 1 case, and multiple complications in 36 cases. In 3 cases, additional posterior cervical surgery was performed. One case needed hardware revision. There were no esophageal, tracheal, or neurovascular structural injuries secondary to metal failure. There were no significant differences in type of plate, level of surgery, or patient factors. The greater the number of fusion segments, the greater the incidence of complications (P = 0.001). The clinical outcomes improved regardless of the complications (P = 0.083). CONCLUSIONS: Most hardware-related complications are not symptomatic and can be treated conservatively. Only a few cases need revision surgery. Precise surgical techniques are needed in multilevel anterior cervical discectomy and fusion (>3 levels) because of the increased complication rate.

Etiology and Related Factors of Postoperative Delirium in Orthopedic Surgery.

BACKGROUND: Delirium is a serious complication for elderly patients after orthopedic surgery. The purpose of this study was to assess the etiology and related factors of delirium after orthopedic surgery in Korea. METHODS: We retrospectively reviewed the medical records of 3,611 patients over 50 years who had orthopedic surgery. The age of patients (50s, 60s, 70s, and > 80s), type of anesthesia (general, spinal, and local), operation time (more than 2 hours vs. less than 2 hours), surgical site (spine, hip, knee, or others), and etiology (trauma or disease) were compared to determine possible risk factors of delirium after orthopedic surgery. RESULTS: Of 3,611 patients, 172 (4.76%) were diagnosed with delirium after orthopedic surgery. Postoperative delirium occurred in 1.18% in their 50s, 3.86% in their 60s, 8.49% in their 70s, and 13.04% in > 80s (p < 0.001). According to anesthesia type, 6.50% of postoperative delirium occurred after general anesthesia, 0.77% after spinal anesthesia, and 0.47% after local anesthesia (p < 0.001). More than 2 hours of operation was associated with higher occurrence of delirium than less than 2 hours was (5.88% vs. 4.13%, p = 0.017). For the etiology, 8.17% were trauma cases and 3.02% were disease (p < 0.001). Postoperative delirium occurred in 22 of 493 patients (4.46%) after spine surgery, 18 of 355 patients (5.07%) after hip surgery, 17 of 394 patients (4.31%) after knee surgery, and 15 of 1,145 patients (1.31%) after surgery at other sites (p < 0.001). CONCLUSIONS: Postoperative delirium was more common in older patients who had surgery under general anesthesia, whose surgery took more than 2 hours, and who were hospitalized through the emergency room.

Anterior cervical discectomy and fusion can restore cervical sagittal alignment in degenerative cervical disease.

OBJECTIVE: The purpose of this study was to evaluate its effect on the restoration and maintenance of cervical sagittal alignment in usual cervical degenerative diseases without preoperative sagittal malalignment. MATERIALS AND METHODS: We retrospectively evaluated 108 patients who were diagnosed with degenerative cervical disease and underwent ACDF (allograft and plating) with > 1-year follow-up. For radiographic evaluation, we analysed segmental and C2-7 cervical lordosis, disc height, C2-7 sagittal vertical axis (SVA), T1 slope, and T1 slope minus C2-7 lordosis (T1S - CL) in lateral X-ray. Clinical assessment was based on arm VAS, neck VAS, and NDI scores. Correlation analysis was performed across the pre-post-changes in radiological parameters. Correlations between the changes in radiological and clinical parameters at final follow-up were also analysed. RESULTS: C2-7 lordosis was 7.13° preoperatively and increased to 13.06° (p < 0.001) and maintained at 10.08° at final follow-up (p = 0.007). Segmental lordosis increased from 0.66° to 8.33° and maintained at 5.19° (p < 0.001). Segmental disc height was 4.67 mm preoperatively (increased to 7.13 mm postoperatively and decreased to 5.74 mm at final follow-up) (p < 0.001). SVA distance (31.53 mm to 30.02 mm) (p = 0.750) and T1 slope (30.03° to 31.37°) did not show meaningful change after surgery. Increase in segmental lordosis was correlated to an increase in C2-7 lordosis (p < 0.001). C2-7 SVA change correlated with both the T1 slope change (p < 0.001) and T1S - CL (p = 0.012). Change in SVA was correlated to a change in segmental lordosis and T1 slope (p = 0.003, p = 0.014). Clinical outcomes did not correlate with radiological findings. CONCLUSION: ACDF for the treatment of degenerative cervical disease without preoperative deformity was effective in restoring cervical sagittal alignment. Improvement of segmental lordosis related to an improvement in C2-7 lordosis and SVA. Radiological sagittal alignment did not show any relation with clinical outcomes in usual degenerative cases.

Posterior Sublaminar Wiring and/or Transarticular Screw Fixation for Reducible Atlantoaxial Instability Secondary to Symptomatic Os Odontoideum: A Neglected Technique?

STUDY DESIGN: Retrospective case analysis. PURPOSE: We retrospectively evaluated the clinical and radiological outcomes of posterior sublaminar wiring (PSLW) and/or transarticular screw fixation (TASF) for reducible atlantoaxial instability (AAI) secondary to os odontoideum. OVERVIEW OF LITERATURE: Limited information is available about the surgical outcomes of symptomatic os odontoideum with AAI. METHODS: We examined 23 patients (12 women and 11 men) with os odontoideum and reducible AAI. The average age of the patients at the time of the operation was 44.2 years. The average follow-up duration was 4.5 years. Thirteen patients with anterior AAI underwent PSLW alone, while 10 patients with combined (anterior+posterior) AAI underwent PSLW and TASF. An autogenous iliac bone graft was used for all patients. Nine patients complained of neck or suboccipital pain, and 14 complained of myelopathy. RESULTS: Angulational instability (preoperative 18.7°±8.9° vs. postoperative 2.1°±4.6°, p<0.001), translational instability (16.3±4.9 mm vs. 1.8±2.2 mm, p<0.001), and segmental angle of the C1-C2 joint (23.7°±7.2° vs. 28.4°±3.8°, p<0.05) showed significant improvement postoperatively. Neck Visual Analog Scale score (6.2±2.4 vs. 2.5±1.8, p<0.05) and the modified Japanese Orthopedic Association (9.1±3.1 vs. 13.2±2.6, p<0.05) score also improved, with a recovery rate of 51.8%. Among the three patients who developed nonunion and/or wire breakage, one underwent revision surgery with repeat PSLW and was finally able to achieve fusion. The final fusion rate was 91.3%. CONCLUSIONS: PSLW and/or TASF provided satisfactory clinical and radiological outcomes in reducible AAI secondary to os odontoideum without significant neurological complications. Our results suggest that PSLW and/or TASF can be considered a viable surgical option over segmental fixation in highly selected cases of os odontoideum with reducible AAI.

Cervical radiculopathy combined with cervical myelopathy: prevalence and characteristics.

Patients with cervical myelopathy may experience symptoms of radiculopathy, and it is not easy to determine whether these symptoms are caused by the myelopathy itself or by a radiculopathy accompanied by root compression. Therefore, we aimed to investigate the prevalence of radiculopathy combined with cervical myelopathy and to evaluate the characteristics of cervical myelopathy with or without radiculopathy. We enrolled 127 patients with cervical myelopathy in this retrospective study and reviewed their medical records and magnetic resonance imaging findings. They were divided into two groups according to the presence of cervical radiculopathy, and their age, sex, involved spinal segment, cord signal change, surgical method, clinical status were compared, and postsurgical recovery was compared using four clinical questionnaires. The incidence and level of radiculopathy combined with myelopathy were investigated. Combined cervical radiculopathy and myelopathy was diagnosed in 66 patients (51.9%, group 1), whereas 61 patients did not have radiculopathy (group 2). There was no difference in sex, age, cord signal change, preoperative Japanese Orthopedic Association score, neck disability index, and neck visual analogue scale (VAS) between the two groups, but group 1 showed higher preoperative arm VAS score (p = 0.001). Postoperative arm and neck VAS scores were significantly improved in group 1 (p = 0.001 and 0.009). Half of the patients had combined cervical myelopathy and radiculopathy. A high preoperative arm VAS score was a characteristic of radiculopathy combined with myelopathy.

Selective laminectomy for cervical spondylotic myelopathy: a comparative analysis with laminoplasty technique.

INTRODUCTION: The purpose of this study was to evaluate the effectiveness of selective laminectomy compared with laminoplasty for patients with multilevel cervical spondylotic myelopathy (CSM) by evaluating the radiological and clinical outcomes. METHODS: We retrospectively reviewed 67 patients with who underwent posterior laminectomy (LN) or laminoplasty (LP). LN was performed in 32 cases and LP in 35 cases. Radiologically, we evaluated the neutral C2-7 Cobb angle and range of motion (ROM) preoperatively and at final follow-up. Preoperative spinal cord compression and expansion of the spinal cord area postoperatively was evaluated using MRI. Differences in operating time and intraoperative and postoperative bleeding were analyzed. The clinical outcome was analyzed using the neck disability index (NDI) and the visual analog scale (VAS) for neck pain. RESULTS: Surgery was performed on 2.04 segments in the LN group and 4.06 in the LP group. Cobb angle and ROM significantly decreased in the LN group at the final follow-up. No difference was found in the preoperative cord compression ratio or extent of expansion of the spinal cord postoperatively. The laminectomy group had a significantly shorter operation time and less intraoperative and postoperative bleeding. Both groups showed improved NDI, JOA score, and VAS for neck pain after surgery, with no significant differences. CONCLUSION: Selective posterior laminectomy for the treatment of multilevel CSM showed advantages of shorter operation time and less blood loss, without a significant difference in clinical outcome, when compared with laminoplasty. However, postoperative kyphosis and decreased range of motion were limitations of laminectomy.

Acute airway obstruction due to postoperative retropharyngeal hematoma after anterior cervical fusion: a retrospective analysis.

BACKGROUND: Acute airway obstruction (AAO) after anterior cervical fusion (ACF) can be caused by postoperative retropharyngeal hematoma, which requires urgent recognition and treatment. However, the causes, evaluation, and appropriate treatment of this complication are not clearly defined. The purpose of this retrospective review of a prospective database was to investigate etiologic factors related to the development of AAO due to postoperative hematoma after ACF and formulate appropriate prevention and treatment guidelines. METHODS: Cervical spinal cases treated at our academic institutions from 1998 to 2013 were evaluated. Demographic data, including factors related to hemorrhagic tendency, and operative data were analyzed. Patients who developed a hematoma were compared with those who did not to identify risk factors. Cases complicated by hematoma were reviewed, and times until development of hematoma and surgical evacuation were determined. Degrees of airway compromise and patient behavior were classified and evaluated. Treatment was selected according to the patient's status. RESULTS: Among 785 ACF procedures performed, there were nine cases (1.15%) of AAO. None of these nine patients had preoperative risk factors. In six patients (67%), the hematoma occurred within 24 h, whereas three patients (33%) presented with hematoma at a median of 72 h postoperatively. Four of the nine patients with AAO underwent evacuation of the hematoma. Two patients with inspiratory stridor, anterior neck swelling, and facial edema progressed to respiratory distress and their hematomas were removed by surgery, during which, sustained superficial venous bleeding was confirmed. Intubation was attempted several times in one patient with cyanosis, but is unsuccessful; cricothyroidotomy was performed in this patient and pumping in the small muscular arterial branches was confirmed in the operating room. All of the patients recovered without any complications. CONCLUSIONS: With rapid recognition and appropriate treatment, there were no long-term complications caused by postoperative hematoma. There were no specific preoperative risk factors for hematoma. Systematic evaluation and appropriate management can be helpful for preventing serious complications after development of a postoperative hematoma.

Are There Differences in the Progression of Ossification of the Posterior Longitudinal Ligament Following Laminoplasty Versus Fusion?: A Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis of studies for the treatment of cervical myelopathy with ossification of the posterior longitudinal ligament (OPLL) treated with laminoplasty or fusion. OBJECTIVE: To delineate whether OPLL continues to progress after laminoplasty compared with fusion and to clarify the relationship between radiological progression of OPLL and neurological decline. SUMMARY OF BACKGROUND DATA: Laminoplasty is usually performed in patients with multilevel OPLL due to the surgical morbidity of anterior surgery. However, the disadvantage of laminoplasty is that the remaining OPLL can progress after the surgery. METHODS: A literature search of PubMed, Embase, Web of Science, and the Cochrane library was performed to identify investigations concerning the progression of OPLL after laminoplasty or fusion. The pooled results were analyzed by calculating the effect size based on the event rate and the logit event rate. RESULTS: We included data from 11 studies involving 530 patients, of whom 429 underwent laminoplasty and 101 underwent fusion surgery. The prevalence of radiological OPLL progression was 62.5% (95% confidence interval [CI] 55.3%-69.3%) for the laminoplasty group and 7.6% (95% CI 3.4%-15.9%) for the fusion group. The laminoplasty displayed substantially high prevalence of the progression of OPLL compared with the fusion group. In the laminoplasty group, the prevalence of OPLL progression increased with time and reached 60% at about 10-year follow-up. The prevalence for neurological decline was similar for about 2 years, 8.3% (95% CI 3.7%-17.9%) for the laminoplasty group and 3.8% (95% CI 1.3%-10.2%) for the fusion group. CONCLUSION: Laminoplasty frequently induces progression of OPLL compared with fusion surgery, but does not make significant clinical deterioration. However, laminoplasty may not be recommended for OPLL patient because it can be getting worse with time. LEVEL OF EVIDENCE: 1.

Relationship between magnetic resonance imaging findings and spinal cord injury in extension injury of the cervical spine.

OBJECTIVE: The purpose of this study was to determine the relationship between magnetic resonance imaging (MRI) findings and neurologic symptoms in cervical spine extension injury and to analyze the MRI parameters associated with neurologic outcome. MATERIALS AND METHODS: This study included 102 patients with cervical spine extension injury, whose medical records and MRI scans at the time of injury were available. Quantitative MRI parameters such as maximum spinal canal compression (MSCC), maximum cord compromise (MCC), and lesion length showing intramedullary signal changes were measured. Furthermore, intramedullary hemorrhage, spinal cord edema, and soft tissue damage were evaluated. Fisher's exact test was used for a cross-analysis between the MRI findings and the three American Spinal Injury Association category groups depending on the severity level of neurologic injury: complete (category A), incomplete (categories B-D), and normal (category E). RESULTS: MSCC accounted for 23.05, 19.5, and 9.94 % for the complete, incomplete, and normal AIS categories, respectively, without showing statistically significant differences (P = 0.085). MCC was noted in 22.05, 15.32, and 9.2 %, respectively, with the complete-injury group (AIS category A) showing significantly higher. In particular, cases of complete injury had >15 % compression, accounting for 87.5 % (P < 0.001). The mean intramedullary lesion length was significantly higher in complete-injury patients than in incomplete-injury patients (24.22 vs. 8.24 mm). Intramedullary hemorrhage and spinal cord edema were significantly more frequently observed in complete-injury cases (P < 0.001). The incidence of complete injury was proportional to the severity of soft tissue damage. CONCLUSION: MCC, intramedullary lesion length, intramedullary hemorrhage, and spinal cord edema were MRI parameters associated with poor neurologic outcomes in patients with cervical spine extension injury.

Significance of Intramedullary High Signal Intensity on Magnetic Resonance Imaging in Patients with Cervical Ossification of the Posterior Longitudinal Ligament.

BACKGROUND: The purpose of this study was to analyze the relation between intramedullary high signal intensity (IMHS) on magnetic resonance imaging (MRI), radiographic parameters, and clinical symptoms in cervical ossification of the posterior longitudinal ligament (OPLL) patients. METHODS: Two hundred forty-one patients, who underwent simple radiography, computed tomography (CT), and MRI were included in the present study. As radiographic parameters, the OPLL occupying ratio and occupying area were measured on CT images. Dynamic factors were assessed by measuring cervical range of motion (ROM) on simple radiographs. Visual analog scale (VAS) for neck and arm pain, and Japanese Orthopaedic Association (JOA) scores were evaluated for clinical analysis. The differences in radiographic and clinical findings were assessed between patients with IMHS on T2-weighted MRI findings (group A) and patients without IMHS (group B). RESULTS: Eighty-one patients were assigned to group A and 160 patients to group B. The occupying ratios were found to be higher in group A than in group B on both sagittal and axial views (p < 0.01). Group A also showed a higher area occupying ratio (p < 0.01). The length and area of underlying spinal canal on the sagittal and cross-sectional planes were lower in group A than in group B (p < 0.01). No significant difference in ROM was observed (p = 0.63). On the clinical findings, group A had a lower JOA score (p < 0.001), and no intergroup differences in VAS scores were observed. CONCLUSIONS: In cervical OPLL cases, IMHS on MRI was associated with manifestation of myelopathic symptom. Occupying ratio was associated with high signal intensity on MRI, whereas no association was found with ROM. Occurrence of high signal intensity increased inversely with the length and area of underlying spinal canal.

Efficacy of Zero-Profile Implant in Anterior Fusion to Treat Degenerative Cervical Spine Disease: Comparison with Techniques Using Bone Graft and Anterior Plating.

BACKGROUND: The efficacy of anterior fusion using zero-profile implant (Zero-P) in the surgical treatment of degenerative cervical disease was investigated through radiographic and clinical comparisons with existing treatments using autograft or allograft and anterior plating. MATERIAL AND METHODS: A total of 130 patients who underwent anterior decompression and fusion for degenerative cervical spine disease with a follow-up of at least 1 year were analyzed retrospectively. The cases were divided into three groups: autograft and plate (38 cases, group A), allograft and plate (44 cases, group B), and Zero-P (48 cases, group C). Maintenance of lordosis, extent of subsidence, and fusion were evaluated radiologically and compared among preoperative, postoperative, and final follow-up time points. In addition, changes in Visual Analog Scale (VAS) and Neurologic Disability Index (NDI) scores and the presence of complications were evaluated for clinical analysis. RESULTS: Operation time was significantly less in group C (p = 0.007, 0.002). Maintenance of entire and segmental lordosis after surgery was better in groups A and B compared with group C (p = 0.002, 0.001); however, the extent of loss of lordosis from the surgery to the final follow-up did not show any significant differences. Regarding the extent of subsidence, the increase of height between the vertebral bodies after the surgery was 3.10, 2.89, and 2.68 mm in group A, group B, and group C, respectively (p = 0.14), and changed to - 1.27, - 2.41, and - 1.2 mm at the final follow-up (p = 0.012). VAS and NDI scores were improved from 7.2 to 3 and 34 to 12, respectively, but there were no significant differences. Nonunion occurred in two cases in both group B and group C. In terms of clinical complications, two cases of persistent donor site pain were found in group A; one case of persistent dysphagia was found in both group A and group B. CONCLUSION: Anterior cervical fusion using Zero-P has a shorter operation time and less subsidence compared with conventional surgical techniques. Thus it can be considered a useful technique for the surgical treatment of degenerative cervical disease.

Prognostic factors in distractive extension injuries of the subaxial cervical spine.

BACKGROUND: The subaxial spine has high risk of fatal damage by trauma and thereby requires more accurate and aggressive treatment. For the proper treatment and predicting the prognosis, the evaluation to reveal the risk factors for the prognosis is important. We analyzed the various factors contributing to the prognosis in distractive extension injuries of the subaxial cervical spine. METHODS: The study included 103 patients who were diagnosed as distractive extension injury of subaxial cervical spine. We evaluate the patient age, sex, cause of injury, initial neurological impairment, number and portion of injured segment, spinal stenosis, extent of soft tissue damage, ossification of the posterior longitudinal ligament, and degenerative spondylosis as a prognostic factor. To analyze the factor related with prognosis, the subjects were divided into group A, in which patients had neurological recovery ≥grade 2 on the ASIA scale or showed normal in final follow-up and group B, in which patients have no neurological recovery. RESULTS: Prognosis was not associated with age, sex, and cause of injury (P = 0.677, 0.541, and 0.965, respectively). Prognosis was poor in cases with spinal stenosis (P = 0.009), soft tissue damage ≥grade 3 on magnetic resonance imaging (MRI) (P = 0.002), or severe neurological impairment (P ≤ 0.001). Logistic regression analysis also showed that prognosis was poor in cases with spinal stenosis (OR 5.03; 95% CI 1.20-16.93), soft tissue damage ≥grade 3 on MRI (OR 7.63; 95% CI 1.86-31.34), or severe neurological impairment (ASIA C, D, OR 0.59, 95% CI 0.14-2.41; ASIA A, B, OR 18.43, 95% CI 1.64-207.69). CONCLUSION: The prognosis of patients with distractive extension injury of the subaxial cervical spine was poor in cases with spinal stenosis, severe soft tissue damage in MRI findings or severe initial neurological impairment.

Reversal of paraplegia after anterior decompression in a patient underwent posterior decompression and fusion for thoracic ossification of posterior longitudinal ligament.

This report describes a rare clinical entity, thoracic myelopathy due to ossification of the posterior longitudinal ligament (OPLL), and its management. A 40-year-old woman presented with thoracic myelopathy due to OPLL, extending from T2-T9. We performed a posterior laminectomy and instrumented fusion. However, postoperative paraplegia occurred within 36 h post-surgery. Emergent anterior decompression and interbody fusion was performed via the trans-thoracic approach. Neurological deterioration was reversed following this anterior procedure. Posterior decompression and instrumented fusion for thoracic OPLL is less technically demanding and presents a lower risk of neurological complications. However, some controversies remain regarding the prevalence and management of postoperative neurological deterioration associated with this technique. Our patient showed recovery with subsequent anterior decompression when paraplegia occurred after posterior decompression and fusion to treat thoracic OPLL. Additional anterior decompression should be considered when posterior decompression and fusion lead to neurological deterioration.

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

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

Adjacent segment pathology following anterior decompression and fusion using cage and plate for the treatment of degenerative cervical spinal diseases.

STUDY DESIGN: Retrospective study. PURPOSE: To analyze the incidence and prevalence of clinical adjacent segment pathology (CASP) following anterior decompression and fusion with cage and plate augmentation for degenerative cervical diseases. OVERVIEW OF LITERATURE: No long-term data on the use of cage and plate augmentation have been reported. METHODS: The study population consisted of 231 patients who underwent anterior cervical discectomy and fusion (ACDF) with cage and plate for degenerative cervical spinal disease. The incidence and prevalence of CASP was determined by using the Kaplan-Meier survival analysis. To analyze the factors that influence CASP, data on preoperative and postoperative sagittal alignment, spinal canal diameter, the distance between the plate and adjacent disc, extent of fusion level, and the presence or absence of adjacent segment degenerative changes by imaging studies were evaluated. RESULTS: CASP occurred in 15 of the cases, of which 9 required additional surgery. At 8-year follow-up, the average yearly incidence was 1.1%. The rate of disease-free survival based on Kaplan-Meier survival analysis was 93.6% at 5 years and 90.2% at 8 years. No statistically significant differences in CASP incidence based on radiological analysis were observed. Significantly high incidence of CASP was observed in the presence of increased adjacent segment degenerative changes (p<0.001). CONCLUSIONS: ACDF with cage and plate for the treatment of degenerative cervical disease is associated with a lower incidence in CSAP by 1.1% per year, and the extent of preoperative adjacent segment degenerative changes has been shown as a risk factor for CASP.

Change of radiological parameters after interspinous implantation (X-stop®) in degenerative spinal stenosis.

OBJECT: This study was intended to objectively demonstrate the effect of interspinous implantation through preoperative and postoperative radiological analyses in degenerative lumbar spinal stenosis. METHODS: This study included 20 segments of 14 cases that had been diagnosed as spinal stenosis through physical and radiological findings and had interspinous implantation (X-stop(®)). On simple radiography, height and width of the intervertebral foramen, height of the anterior and posterior intervertebral disks, and interbody angle were measured. On magnetic resonance imaging (MRI), the intervertebral foramen and intradural areas were also measured. Changes in preoperative and postoperative measurements were compared, and correlation between radiological indicators was identified. Clinical evaluation was done using visual analog scale (VAS) and Oswestry disability index (ODI) scores. The relationship between the clinical outcomes and radiological changes was also evaluated. RESULTS: The comparison of preoperative and postoperative radiological measurements showed significant changes in height and width of the intervertebral foramen, and interbody angle on simple radiography, and in height of the intervertebral foramen on MRI. Regarding correlation between radiological indicators, there was correlation between height of the intervertebral foramen on simple radiography and area of the intervertebral foramen on MRI, and between the intervertebral foramen and intradural areas on MRI. For correlation between the clinical improvement level and the changes in radiological parameters, VAS correlated with intervertebral foramen height on simple radiography and increased area of the intervertebral foramen on MRI. However, for ODI, there was no factor showing significant correlation. CONCLUSIONS: In patients with degenerative spinal stenosis showing neurogenic claudication, interspinous implantation was more effective in increasing the height and area of the intervertebral foramen than in increasing intradural area, and the short-term clinical results were promising.

Efficacy of postoperative radiograph for evaluating the prevertebral soft tissue swelling after anterior cervical discectomy and fusion.

BACKGROUND: After surgery for degenerative spinal disease by the anterior approach, the degree of soft tissue swelling can be assessed simply using plain radiographs. However, there are little studies according to the surgical methods or extent of surgery, and no study had addressed the clinical meaning of swelling determined by plain radiography. The purpose of this study was to evaluate the clinical significance of prevertebral soft tissue swelling (PSTS) after anterior cervical fusion with plate fixation for the treatment of degenerative cervical spinal disorders. METHODS: One hundred and thirty-five patients that underwent anterior cervical fusion with plate augmentation for degenerative cervical spondylosis were included in this study. PSTS differences were analyzed with respect to numbers of fusion segments and location of fusion. Cases were divided into two groups based on the amount of PSTS, and incidences of dyspnea, dysphagia, dysphonia were evaluated. RESULTS: PSTS increments were significantly greater in patients that had undergone multi-level or high-level fusion. Complications of dyspnea, dysphagia and dysphonia were found more frequently in patients with marked PSTS group. CONCLUSIONS: Increments of PSTS after anterior cervical fusion for degenerative spinal disorders are greater and incidences of complications are higher in patients that undergo multi-level or high-level fusion. Thus, measurement of PSTS using consecutive cervical lateral radiographs after anterior cervical surgery is clinically meaningful procedure.

Ossification of the posterior longitudinal ligament: a review of literature.

Ossification of the posterior longitudinal ligament (OPLL) is most commonly found in men, in the elderly, and in Asian patients. The disease can start with mild or no symptoms, but some patients progress slowly to develop symptoms of myelopathy. An accurate diagnosis through the use plain radiograph, computed tomography, and magnetic resonance imaging findings is very important to monitor the development of symptoms and to make decisions regarding a treatment plan. When symptoms are mild and non-progressive, conservative treatments and periodic observations are good enough, but once symptoms of myelopathy are present and neurologic symptoms are progressive, the treatment of choice is surgery to relieve spinal cord compression. Surgical management of OPLL continues to be controversial. Each surgical technique has some advantages and disadvantages, and the choice of operation should be decided carefully with various considerations. The patient's neurological condition, location and extent of pathology, cervical kyphosis, presence or absence of accompanied instability, and the individual surgeon's experience must be an important factors that should be considered before surgery.