Posterior thoracic antedisplacement and fusion surgery for a special type of ossification of the posterior longitudinal ligament in the thoracic spine: indications and preliminary clinical results of 2-year follow-up.

OBJECTIVES: To describe a novel technique, posterior thoracic antedisplacement and fusion (PTAF), for a special type of ossification of the posterior longitudinal ligament in the thoracic spine (T-OPLL), and to evaluate its safety and efficacy. METHODS: From July to December 2020, five consecutive patients with beak-type T-OPLL located at the thoracic vertebral body (VB) level underwent PTAF surgery. Their demographic data, radiological parameters, perioperative complications, and surgery-related findings were recorded and analyzed. The surgical outcomes were assessed using a modified Japanese Orthopedic Association (mJOA) scale, and the recovery rate (RR) was calculated using the Hirabayashi's method. RESULTS: All patients were followed up for at least two years. The mean thickness of OPLL was 9.4 ± 1.0 mm, and the OPLL spinal canal occupying ratio was 67.7% ± 8.5%. Postoperatively, the mean antedisplacement distance of OPLL was 8.1 ± 1.8 mm, and the average shortened distance of the spinal column was 6.0 ± 1.13 mm. The mean operation time and blood loss were 158.2 ± 26.3 min and 460 ± 89.4 mL, respectively. Perioperative complications were cerebrospinal fluid leakage and instrument failure, 2 cases each. The mean mJOA score was increased from 3.6 ± 2.9 before surgery to 9.4 ± 3.0 at the last follow-up, and the average RR was 84.2 ± 30.5%. CONCLUSION: The preliminary clinical outcomes indicate that PTAF is a safe and effective method for the treatment of beak-type T-OPLL, which has its apex located at the VB level and has a high spinal canal occupation ratio.

Factors associated with non-fusion after direct pars repair of lumbar spondylolysis with pedicle screw and lamina hook: a clinical and CT-assessed study.

BACKGROUND: Pedicle screw and lamina hook (PSLH) technique is an effective and popular method for direct pars repair of lumbar spondylolysis. There is a lack of studies to explore factors that may influence the healing of spondylolysis after direct pars repair surgery. The present study aimed to investigate the factors associated with non-fusion after direct pars repair of lumbar spondylolysis with PSLH technique. METHODS: A total of 55 subjects (average age 21.1 ± 6.3 years, a total of 120 pars defects) diagnosed with symptomatic spondylolysis and underwent pars repair surgery with PSLH were followed up and their clinical data were analyzed. Subjects were divided into a non-fusion group and fusion group according to whether the pars defect had bony fusion at last follow-up assessed by CT. Radiographic data, data related to spondylolysis and clinical outcomes were collected and compared between groups. RESULTS: The mean follow-up time of the 55 patients was 24.8 ± 12.0 (12-64) months. Among the 120 pars defects, 101 defects were successfully fused and 19 were not fused according to CT. The fusion rate was 84.2%. Multivariable logistic regression analysis showed the factors correlated with non-fusion after pars repair surgery: whether the spondylolysis segment was associated with spina bifida occulta (SBO) (P = 0.001), stage of the defect (P = 0.047), width of the defect (P = 0.002), and disc degeneration (P = 0.014). CONCLUSION: Direct pars repair by PSHL is a reliable treatment for lumbar spondylolysis with a fusion rate of 84.2%. Association with SBO of the spondylolysis segment, a terminal stage of the defect, a wider defect gap, and grade III disc degeneration may be factors associated with non-fusion after direct pars repair of lumbar spondylolysis with PLSH. Non-fusion patients after pars repair appear to have worse clinical results compared to fusion patients.

Factors Affecting the Surgical Outcomes of Patients Treated With "de-tension" Surgical Strategy for Multilevel Ossification of the Posterior Longitudinal Ligament in the Thoracic Spine: A Minimum 2-year Follow-Up Study of 83 Patients in a Single Center.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To describe the clinical characteristics and surgical outcomes of patients with multilevel-ossification of the posterior longitudinal ligament (mT-OPLL), and to identify risk factors for unfavorable outcomes. METHODS: Patients who were diagnosed with mT-OPLL and underwent one-stage thoracic posterior laminectomy combined with selective OPLL resection, spinal cord de-tension, and fusion surgery between August 2012 and October 2020 were recruited. Patients' demographic-, surgical- and radiological-related parameters were collected and analyzed. Neurological status was evaluated with mJOA score, and recovery rate (RR) was calculated using the Hirabayashi formula. According to RR, patients were divided into a favorable outcome group (FOG, RR ≥50%) and an unfavorable outcome group (UOG, RR <50%). Univariate and multivariate analyses were used to compare the difference between the 2 groups and to identify risk factors for unfavorable outcomes. RESULTS: A total of 83 patients were included, with an average age of 50.6 ± 8.3 years. Cerebrospinal fluid leakage (60.2%) and transient neurological deterioration (9.6%) were the most common complications. The average mJOA score improved from preoperative 4.3 ± 2.2 to 9.0 ± 2.4 at the last follow-up, and the mean RR was 74.9 ± 26.3%. Disease duration, preoperative nonambulatory status, and the number of decompressed levels were identified as potential risk factors by Univariate analysis (all P < .05). Multivariate analysis showed that the preoperative disease duration and nonambulatory status were independent risk factors for unfavorable outcomes. CONCLUSIONS: Long disease duration and nonambulatory status before surgery were independent risk factors for unfavorable outcomes.

Risk Factors and Three Radiological Predictor Models for the Progression of Proximal Junctional Kyphosis in Adult Degenerative Scoliosis Following Posterior Corrective Surgery: 113 Cases With 2-years Minimum Follow-Up.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To identify risk factors and predictive models for proximal junctional kyphosis (PJK) in a long-term follow-up of patients with adult degenerative scoliosis (ADS) following posterior corrective surgeries. MATERIALS AND METHODS: A consecutive 113 ADS patients undergoing posterior corrective surgery between January 2008 and April 2019 with minimum 2-year follow-up were included. All patients underwent preoperative, postoperative, and final follow-up by X-ray imaging. Multivariate logistic analysis was performed on various risk factors and radiological predictor models. RESULTS: PJK was identified radiographically in 46.9% of patients. Potential risk factors for PJK included postoperative thoracic kyphosis (TK) (P < .05), final follow-up Pelvic Tilt (PT) (P < .05), PT changes at final follow-up (P < .05), age over 55 years old at the surgery (P < .05), theoretical thoracic kyphosis-actual thoracic kyphosis mismatch (TK mismatch) (P < .05) and theoretical lumbar lordosis-acutal lumbar lordosis mismatch (LL mismatch) (P < .05). As for the predictive models, PJK was predictive by the following indicators: preoperative global sagittal alignment ≥45° (Model 1), postoperative pelvic incidence-lumbar lordosis mismatch (PI-LL)≤10° and postoperative PI-LL overcorrection (Model 2), and TK+LL≥0° (Model 3) (P < .05). Postoperative TK mismatch (OR = 1.064) was independent as risk factors for PJK, with the cut-off values respectively set at -28.56° to predict occurrence of PJK. CONCLUSION: The risk of radiographic PJK increases with an age over 55 years old and higher postoperative TK. In addition, postoperative TK mismatch is an independent risk factor for developing PJK. All three predictive models could effectively indicate the occurrence of PJK.

Robot-assisted percutaneous vertebroplasty for osteoporotic vertebral compression fractures: a retrospective matched-cohort study.

PURPOSE: This study aims to introduce the principle, clinical efficacy, and learning curve of robot-assisted percutaneous vertebroplasty (PVP). METHODS: Forty-two patients who underwent robot-assisted single-level PVP were analyzed retrospectively and 42 age-matched patients using freehand technique were selected as the control group. The visual analog scale, operation time, radiation exposure, accuracy, and learning curve were analyzed. RESULTS: The puncture time and total operation time were significantly shorter, and the puncture and total fluoroscopy number were fewer in the robot group. The deviation between pre-operative planned and actual puncture trajectory well met clinical requirement. The puncture time, total operation time, and puncture fluoroscopy number were significantly more in early cases than in later cases in the robot group. CONCLUSION: The robot-assisted pedicle puncture technique shortens the operation time and reduces radiation exposure, and the accuracy meets the clinical requirement in PVP. The learning curve is short and not steep.

Significance of body mass index on thoracic ossification of the ligamentum flavum in Chinese population.

PURPOSE: To investigate the risk factors for thoracic ossification of the ligamentum flavum (TOLF), especially the relationship between BMI and TOLF. METHODS: A total of 856 individuals consisting of 326 controls without ossification of spinal ligaments and 530 TOLF inpatients who underwent thoracic spine decompression surgery at our hospital between January 2013 and September 2020 were included. All subjects were classified into 4 grades: Grade 0) control; Grade 1) single-segment TOLF; Grade 2) multi-segment TOLF; and Grade 3) TOLF combined thoracic ossification of the posterior longitudinal ligament (T-OPLL). Logistic regression analysis was performed to identify the risk factors for TOLF. The TOLF index was calculated to assess the severity of TOLF, and its relationship with BMI was investigated by correlation analysis. RESULTS: Overall, TOLF patients are most numerous in the 50-59 age group. Age and gender were considered as independent risk factors for Grades 1 and 2. BMI was identified as an independent risk factor for TOLF. Furthermore, BMI was significantly higher in Grade 1 (26.1 VS 24.5 kg/m2, P = 0.0001), Grade 2 (28.2 VS 24.5 kg/m2, P < 0.0001), and Grade 3 (29.1 VS 24.5 kg/m2, P < 0.0001) than Grade 0. Notably, in TOLF patients without combined T-OPLL, BMI was positively correlated with TOLF index, while BMI was negatively correlated with age in younger individuals. CONCLUSION: BMI is a crucial risk factor for TOLF. It highlights the necessity of close follow-up of asymptomatic TOLF patients with high BMI to detect and treat their TOLF progression promptly.

Scoliosis in dysplastic spondylolisthesis: a clinical survey of 50 young patients.

BACKGROUND: Dysplastic spondylolisthesis is a rare spinal deformity that occurs mainly in young patients. Although its sagittal parameters had been well stated, coronal abnormalities in these patients were poorly studied. The purposes of this study were: (1) to investigate the prevalence of scoliosis in dysplastic spondylolisthesis;(2) to assess scoliosis resolution or persistence after surgery; and (3) to propose a modified classification of scoliosis associated with dysplastic spondylolisthesis. METHODS: Fifty patients (average age 14.9 ± 5.6 years) diagnosed with dysplastic spondylolisthesis who underwent surgical treatment were followed up and their data were analyzed. Standing posteroanterior and lateral full spine radiographs were used to measure the coronal and sagittal parameters. Patients with scoliosis, which was defined as a coronal Cobb angle greater than 10°, were divided into three groups according to their curve characteristics: "independent" scoliosis (IS) group, spasm scoliosis (SS) group, and olisthetic scoliosis (OS) group. SS and OS were spondylolisthesis-induced scoliosis. The radiographic parameters and patient-reported outcomes were collected before and after surgery and compared between groups. RESULTS: The average slip percentage was 62.8% ± 23.1% and the average follow-up time was 51.5 ± 36.4 months (range 3-168 months). Twenty-eight of the 50 (56%) dysplastic spondylolisthesis patients showed scoliosis, of which 8 were IS (24.7° ± 15.2°), 11 were SS (13.9° ± 3.0°), and 9 were OS (12.9° ± 1.9°). By the last follow-up, no scoliosis resolution was observed in the IS group whereas all SS patients were relieved. Of the nine patients with OS, four (44.4%) had scoliosis resolution after surgery. CONCLUSION: Distinguishing different types of scoliosis in dysplastic spondylolisthesis patients may help surgeons to plan treatment and understand prognosis. For patients with significant scoliosis, whether "independent" or spondylolisthesis-induced, treatment of spondylolisthesis should be performed first and scoliosis should be observed for a period of time and treated according to the corresponding principles.

Analysis of Radiographic Spinopelvic Parameters in Patients With Degenerative Lumbar Kyphoscoliosis.

PURPOSE: To analyze the relationships between coronal and sagittal spinopelvic parameters in degenerative lumbar kyphoscoliosis (DLKS). METHODS: We enrolled 75 patients with DLKS for a radiographic study between January 2016 and September 2018. Correlations between coronal and sagittal spinopelvic radiographic parameters were analyzed. Then patients were divided into 2 groups: sagittal balanced group (SVA< = 5 cm, 30 patients) and sagittal imbalanced group (SVA >5 cm, 45 patients), and relevant parameters were compared. RESULTS: The Cobb angle and lumbar lordosis of the DLKS patients were 24.87 ± 11.59° and 17.26 ± 12.24°, respectively. The average age was 68 years old (range: 42-82), and the sex ratio was 2.6:1 (female: 54 patients; male: 21 patients). 50 patients (66.7%) located convexity of the curve at left side, while 25 patients (33.3%) at right side. The Cobb angle correlated with LL-TK (r = -0.228, p = 0.049), LL (r = -0.255, p = 0.027) and SS (r = -0.232, p = 0.045). There were significant differences in PI-LL (t = -3.484, P = 0.001), LL-TK (t = 2.354, P = 0.023), PI (t = -3201, P = 0.002) and PT (t = -2.521, P = 0.014) between sagittal balanced and imbalanced group. CONCLUSIONS: In degenerative lumbar kyphoscoliosis, there are some correlations between coronal and sagittal spinopelvic parameters. Moreover, PI-LL, LL-TK, PI, PT were significantly different between sagittal balanced and imbalanced DLKS patients.

Ultrasonic bone scalpel for thoracic spinal decompression: case series and technical note.

BACKGROUND: Thoracic spinal stenosis (TSS) is a rare but intractable disease that fails to respond to conservative treatment. Thoracic spinal decompression, which is traditionally performed using high-speed drills and Kerrison rongeurs, is a time-consuming and technically challenging task. Unfavorable outcomes and high incidence of complications are the major concerns. The development and adaptation of ultrasonic bone scalpel (UBS) have promoted its application in various spinal operations, but its application and standard operating procedure in thoracic decompression have not been fully clarified. Therefore, the purpose of this study is to describe our experience and technique note of using UBS and come up with a standard surgical procedure for thoracic spinal decompression. METHODS: A consecutive of 28 patients with TSS who underwent posterior thoracic spinal decompression surgery with UBS between December 2014 and May 2015 was enrolled in this study. The demographic data, perioperative complications, operation time, estimated blood loss, and pre- and postoperative neurological statuses were recorded and analyzed. Neurological status was evaluated with a modified Japanese Orthopaedic Association (JOA) scale, and the neurological recovery rate was calculated using the Hirabayashi's Method. RESULTS: Thoracic spinal decompression surgery was successfully carried out in all cases via a single posterior approach. The average age at surgery was 49.7 ± 8.5 years. The mean operative time of single-segment laminectomy was 3.0 ± 1.4 min, and the blood loss was 108.3 ± 47.3 ml. In circumferential decompression, the average blood loss was 513.8 ± 217.0 ml. Two cases of instrument-related nerve root injury occurred during operation and were cured by conservative treatment. Six patients experienced cerebrospinal fluid (CSF) leakage postoperatively, but no related complications were observed. The mean follow-up period was 39.7 ± 8.9 months, the average JOA score increased from 4.7 before surgery to 10.1 postoperatively, and the average recovery rate was 85.8%. CONCLUSIONS: The UBS is an optimal instrument for thoracic spinal decompression, and its application enables surgeons to decompress the thoracic spinal cord safely and effectively. This standard operating procedure is expected to help achieve favorable outcomes and can be used to treat various pathologies leading to TSS.

Cervical sagittal alignment in adolescent high dysplastic developmental spondylolisthesis: how does the cervical spine respond to the reduction of spondylolisthesis?

BACKGROUND: Although pelvic and related parameters have been well stated in lumbar developmental spondylolisthesis, cervical sagittal alignment in these patients is poorly studied, especially in high dysplastic developmental spondylolisthesis (HDDS). The purpose of this study is to investigate the sagittal alignment of the cervical spine in HDDS and how the cervical spine responds to reduction of spondylolisthesis. METHODS: Thirty-three adolescent patients with lumbar developmental spondylolisthesis who received preoperative and postoperative whole-spine x-rays were reviewed. They were divided into the HDDS group (n = 24, 13.0 ± 2.2 years old) and the low dysplastic developmental spondylolisthesis (LDDS) group (n = 9, 15.6 ± 1.9 years old). Spinal and pelvic sagittal parameters, including cervical lordosis (CL), were measured and compared between groups. In the HDDS group, the postoperative parameters were measured and compared with those before surgery. RESULTS: HDDS group had a higher proportion of cervical kyphosis (70.8% vs. 22.2%, P = 0.019), and there was a significant difference in CL between the two groups (- 8.5° ± 16.1° vs. 10.5° ± 11.8°, P = 0.003). CL was correlated with the Dubousset's lumbosacral angle (Dub-LSA), pelvic tilt (PT), and thoracic kyphosis (TK). In the HDDS group, CL in patients with a kyphotic cervical spine was significantly improved after reduction of spondylolisthesis (- 16.4° ± 5.9° vs. - 3.6° ± 9.9°, P < 0.001). In the HDDS group, 46% (6/13) of the patients with postoperative Dub-LSA < 90° still had sagittal imbalance (sagittal vertical axis, [SVA] > 5 cm), while no sagittal imbalance was observed in patients with postoperative Dub-LSA > 90° (46% [6/13] vs. 0% [0/11], P = 0.016). CONCLUSIONS: HDDS can lead to cervical kyphosis through a series of compensatory mechanisms. Reduction of spondylolisthesis and correction of lumbosacral kyphosis may correct the cervical kyphosis and normalize the overall spinal sagittal profile. Correction of Dub-LSA to above 90° might be used as an objective to better improve the sagittal alignment of the spine.

Preemptive analgesia with a single low dose of intrathecal morphine in multilevel posterior lumbar interbody fusion surgery: a double-blind, randomized, controlled trial.

BACKGROUND CONTEXT: Patients undergoing lumbar spinal surgery may experience considerable pain in the early postoperative period, and poor pain control after multilevel lumbar spinal fusion surgery is frequently associated with multiple complications and delayed discharge from hospital. PURPOSE: The current study evaluated the efficacy and safety of preemptive analgesia with intrathecal morphine (ITM) in patients undergoing multilevel posterior lumbar spinal fusion surgery. STUDY DESIGN: Double-blinded, randomized, controlled trial. PATIENT SAMPLE: Ninety-two patients aged between 18 and 80 years who were scheduled to undergo elective lumbar laminectomy (L3-S1) and dual-level fusions. OUTCOME MEASURES: The primary endpoint was the degree of postoperative pain at rest and during movement evaluated using a 10-point visual analogue scale. The secondary outcomes included the consumption of analgesics, the patient-assessed postoperative and satisfaction scores, adverse effects, time to first ambulation, and length of hospital stay. METHODS: Patients were randomly allocated to either the ITM group that received 0.2 mg of ITM or the control (CON) group that received 2 ml of 0.9% saline as a skin infiltration 30 minutes prior to anesthesia induction. RESULTS: The ITM group had a significantly lower visual analogue scale score than the CON group during the first 3 days postoperatively (at rest, P=0.000, during movement, P=0.000). The ITM group used significantly less sufentanil than the CON group in the first 3 days postoperatively (p=.000) in patient-controlled intravenous analgesia, as well as in supplemental analgesic demands. The ITM group reported a greater degree of satisfaction with the whole hospitalization experience than the CON group (2.4±0.6 vs. 1.9±0.6, p=.000). The two groups did not significantly differ regarding adverse effects, length of hospital stay, and time taken to regain the ability to walk without support. CONCLUSIONS: Preemptive analgesia with ITM results in significantly improved early postoperative pain control and decreased postoperative patient-controlled intravenous analgesia consumption, with no increase in adverse effects.

Two-Level Osteotomy for the Corrective Surgery of Severe Kyphosis From Ankylosing Spondylitis: A Retrospective Series.

STUDY DESIGN: Retrospective study. OBJECTIVE: To describe the treatment results of patients with severe ankylosing spondylitis (AS) kyphosis who underwent two-level osteotomy and correction surgery. SUMMARY OF BACKGROUND DATA: The best solution for the fixed kyphotic deformity of AS is corrective osteotomy. Many osteotomy options are available: pedicle subtraction osteotomy (PSO), Smith-Peterson osteotomy (SPO), and vertical column resection (VCR). These procedures all provide multiplanar deformity correction. Nevertheless, when the AS deformity is severe, an additional osteotomy site to get more correction, achieve more ideal, and smooth curvature of the spine than single osteotomy. METHODS: From May, 2008 to August, 2016, 19 patients of severe AS kyphosis underwent two-level spinal osteotomy and correction surgery. The patients had an average kyphosis angle greater than 90°. The radiological features and clinical evaluation, including Oswestry Disability Index (ODI), visual analog scale (VAS), and Scoliosis Research Society (SRS)-22 components were assessed before surgery and at follow-up. The patients underwent either one-level PSO combined with one-level SPO (n = 9) or two-level PSO (n = 10). RESULTS: The height was increased after surgery in all patients (P < 0.05). The median follow-up was 24 months. The kyphosis angle improved from 92.0 ±â€Š16.6° to 30.0 ±â€Š17.2°. The chin-brow vertical angle improved from 37.6 ±â€Š19.2° to -0.6 ±â€Š2.5°. The sacral slope improved from 3.9 ±â€Š11.8° to 21.7 ±â€Š7.4°. Sagittal imbalance improved from 241.4 ±â€Š115.3 mm to 74.6 ±â€Š48.5 mm (P < 0.05). Lumbar lordosis improved from -3.9 ±â€Š20.8° to 29.4 ±â€Š14.1° (all P < 0.05). There were significant improvements in the ODI, VAS, and all components of SRS-22 (all P < 0.05). All patients with pseudarthrosis (n = 5) underwent PSO + SPO and achieved satisfactory results. Six complications were observed perioperatively, but without permanent sequelae. CONCLUSION: Two-level osteotomy and correction procedure can achieve satisfactory results in severe AS kyphosis. PSO + SPO could be a good option for patients with pseudarthrosis because of relatively easier and faster operation. LEVEL OF EVIDENCE: 4.

[An age-stratified follow-up of complications and clinical benefit of posterior lumbar intervertebral fusion procedure in middle-aged and older patients].

OBJECTIVE: To compare the complications and clinical scores of posterior lumbar intervertebral fusion (PLIF) in middle-aged and older patients of different ages, and to assess the risk of complications of PLIF in different ages, providing a reference for clinical treatment. METHODS: The clinical data of 1 136 patients, who were more than 55 years old and underwent PLIF between June 2013 and June 2016, were retrospectively analyzed. According to the age of patients undergoing surgery, they were divided into 3 groups as 55-64 years old, 65-74 years old, and ≥75 years old. The general characteristics, comorbidities, and surgical data of the three groups were compared, with comparison the morbidity of complications. According to the minimal clinical important difference (MCID), the improvement of patient's pain visual analogue scale (VAS) score and the Oswestry disability index (ODI) score were compared. Univariate logistic regression analysis was used to analyze the difference of complications and the improvement of VAS and ODI scores. Multivariate logistic regression analysis was performed for the risk factors of complications. RESULTS: There were significant differences in the number of surgical fusion segments and osteoporosis between groups ( P<0.05); there was no significant difference in gender, body mass index, operation time, preoperative American Society of Anesthesiologists (ASA) classification, and comorbidities between groups ( P>0.05). All patients were followed up 6-62 months with an average of 27.4 months. Among the results of postoperative complications, there were significant differences in the total incidence of intraoperative complications, systemic complications, minor complications, and the percentage of improvement of ODI score to MCID between groups ( P<0.05); but there was no significant difference in the total incidence of complications at the end of long-term follow-up and the percentage of improvement of VAS score to MCID between groups ( P>0.05). Univariate logistic regression analysis showed that after adjusting the confounding factors, there were significant differences in intraoperative complications and the percentage of improvement of ODI score to MCID between 55-64 and 65-74 years old groups ( P<0.05); systemic complications, minor complications, complications at the end of long-term follow-up, and the percentage of improvement of ODI score to MCID in ≥75 years old group were significantly different from those in the other two groups ( P<0.05). Multivariate logistic regression analysis showed that age was a risk factor for systemic complications, minor complications, and complications at the end of long-term follow-up. Except for age, long operation time was a risk factor for intraoperative complications, increased number of fusion segments was a risk factor for systemic complications, the number of comorbidities was a risk factor for minor complications, and osteoporosis was a risk factor for complications at the end of long-term follow-up. CONCLUSION: The risk of surgical complications is higher in the elderly patients (≥75 years) with lumbar degenerative diseases than in the middle-aged and older patients (<75 years), while the improvements of postoperative VAS and ODI scores were similar. Under the premise of fully assessing surgical indications, PLIF has a positive effect on improving the elderly patients' quality of life.

[Effect of pre-existing adjacent segment degeneration on short-term effectiveness after lumbar fusion surgery].

OBJECTIVE: To analyze the prospective effect of pre-existing spinal stenosis of adjacent segment on the short-term effectiveness after lumbar fusion surgery. METHODS: A prospective comparative study was conducted to divide 183 patients with L 4-S 1 lumbar spinal stenosis who met the selection criteria between July 2015 and December 2017 into two groups according to the status of adjacent segment degeneration (ASD) judged by preoperative disc degeneration and spinal stenosis. There were 98 patients in group A (no degeneration of adjacent segments before operation) and 85 patients in group B (adjacent segments degenerated before operation). There was no significant difference in gender, American Society of Anesthesiologists (ASA) grade, body mass index (BMI), combined spondylolisthesis, and preoperative visual analogue scale (VAS) score of low back pain and leg pain, Japanese Orthopaedic Association (JOA) score, and Oswestry disability index (ODI) score between the two groups ( P>0.05); the age of group A was significantly younger than that of group B ( t=-3.560, P=0.000). The operation time, intraoperative blood loss, hospitalization stay, and perioperative complications were recorded and compared. The VAS score of low back pain and leg pain, JOA score, and ODI score at last follow-up were used to evaluate the effectiveness. The incidence of ASD after operation was compared between the two groups, and logistic regression was used to analyze the independent risk factors affecting the occurrence of ASD after operation. RESULTS: There was no significant difference in operation time, intraoperative blood loss, and hospitalization stay between the two groups ( P>0.05). The incidence of perioperative complications in groups A and B was 13.3% and 20.0%, respectively, with no significant difference ( χ 2=1.506, P=0.220). Two groups of patients were followed up, the follow-up time of groups A and B was (24.9±8.8) months and (24.8±7.8) months, respectively, there was no significant difference ( t=0.050, P=0.960). At last follow-up, no adjacent segment disease was found in either group. There was no significant difference in Pfirrmann grade between the two groups at last follow-up ( P>0.05), and there was significant difference in Pfirrmann grade between the two groups before operation and at last follow-up ( P<0.001). At last follow-up, 21 cases (21.4%) in group A and 53 cases (62.4%) in group B had ASD, with significant difference ( χ 2=31.652, P=0.000). The main cause of ASD was the severity of adjacent spinal canal stenosis. The clinical scores of the two groups at last follow-up were significantly improved when compared with those before operation ( P<0.05). The JOA score of group A was significantly higher than that of group B at last follow-up ( P<0.05). In group B, the VAS score of low back pain and ODI score in patients with ASD after operation at last follow-up were significantly higher than those in patients without ASD ( P<0.05). logistic regression analysis showed that preoperative pre-existing degeneration and BMI were independent risk factors for ASD after operation ( P<0.05). CONCLUSION: Pre-existing mild spinal stenosis in adjacent segment can significantly affect the effectiveness, and can significantly increase the risk of ASD early after operation. The main pathological type of ASD was the severity of adjacent segment spinal stenosis. For preoperative assessment of pre-existing degeneration, we should evaluate the overall degeneration of the adjacent segment of the spinal canal, rather than simply evaluating the degeneration of the adjacent disc and facet joints.

Polymicrobial and Monomicrobial Infections after Spinal Surgery: A Retrospective Study to Determine which Infection is more Severe.

STUDY DESIGN: A retrospective clinical review. PURPOSE: To investigate the difference in clinical manifestations and severity between polymicrobial and monomicrobial infections after spinal surgery. OVERVIEW OF LITERATURE: Surgical site infections (SSIs) after spinal surgery are a major diagnostic and therapeutic challenge for spinal surgeons. Polymicrobial infections after spinal surgery seem to result in poorer outcomes than monomicrobial infections because of complementary resistance to antibiotics. However, comparison of the clinical manifestations and severity between polymicrobial and monomicrobial infections are limited. METHODS: Sixty-seven patients with SSIs after spinal surgery were studied: 20 patients with polymicrobial infections and 47 with monomicrobial infections. Pathogenic bacteria identified were counted and classified. Age, sex, and body mass index were compared between the two groups to identify homogeneity. The groups were compared for clinical manifestations by surgical site, postoperative time to infection, infection site, incisional drainage, incisional swelling, incisional pain, neurological signs, temperature, white blood cell count, and the percentage of neutrophils. Finally, the groups were compared for severity by hospital stay, number of rehospitalizations, number of debridements, duration of antibiotics administration, number of antibiotics administered, and implant removal. RESULTS: Polymicrobial infections comprised 29.9% of SSIs after spinal surgery, and most polymicrobial infections (70.0%) were caused by two species of bacteria only. There was no difference between the groups in terms of clinical manifestations and severity. In total, 96 bacterial strains were isolated from the spinal wounds: 60 strains were gram-positive and 36 were gram-negative pathogenic bacteria. Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli, and Enterobacter cloacae were cultured in order of the frequency of appearance. CONCLUSIONS: Most polymicrobial infections were caused by two bacterial species after spinal surgery. There was no difference in clinical manifestations or severity between polymicrobial and monomicrobial infections.

Posterior corrective surgery for moderate to severe focal kyphosis in the thoracolumbar spine: 57 cases with minimum 3 years follow-up.

PURPOSE: To evaluate the radiological and clinical outcomes of the corrective surgery for patients with moderate to severe focal kyphosis in thoracolumbar spine. METHODS: Fifty-seven patients with moderate to severe focal kyphosis of the thoracolumbar spine underwent apical segmental resection osteotomy with dual axial rotation correction at our hospital. There were 30 male and 27 female patients. The mean age was 34.3 years. The kyphosis level radiographs were obtained from each patient before surgery, immediately after surgery and at follow-up. Local kyphosis and scoliosis Cobb angles were measured. Full-spine standing radiographs were obtained before surgery and at follow-up, and the spine sagittal and coronal balance were evaluated. The height of patients, the Frankel grading system for neurological functions, the Oswestry disability index for life quality, the visual analogue score for back pain and the patient satisfactory index for satisfaction to surgery were applied before surgery and at follow-up. The radiological and clinical outcomes were further analyzed in different sub-groups of patients according to etiology, severity of kyphosis, age, level of kyphosis apex, Frankel grade before surgery, and complications. RESULTS: The average follow-up time of patients was 46.1 months. The average kyphosis angle reduced from 94.6° before surgery to 31.0° immediately after surgery, and remained at 34.4° at follow-up. The sagittal balance of the spine, height of patients, Frankel grading, Oswestry disability index and visual analogue score were improved. The patient satisfactory index (PSI) showed a satisfied rate of 91.2%. The correction rate was significantly higher in patients with kyphosis angle less than 95° and age less than 35 years. The clinical improvement rate was significantly higher in patient with kyphosis apex at lower thoracic spine or thoracolumbar segment, Frankel grade E before surgery and no complication group. The incidence of intra-operative and early stage complications was 38.6%, and the incidence of instrumentation failure was 10.5%. The most severe complication was transient spinal cord injury, and the incidence was 7.0%. All complications got good relief after appropriate intervention. CONCLUSIONS: Apical segmental resection osteotomy with dual axial rotation correction is an effective procedure to treat moderate to severe focal kyphosis, the prevention of serious neurological complications is fundamental to achieve the ideal clinical results.

Clinical Features of Thoracic Spinal Stenosis-associated Myelopathy: A Retrospective Analysis of 427 Cases.

STUDY DESIGN: This was a retrospective review. OBJECTIVE: The aim of this study was to examine the epidemiological characteristics and causes of spinal cord compression in thoracic spinal stenosis (TSS). SUMMARY OF BACKGROUND DATA: As the thoracic spinal canal is relatively narrow and the thoracic cord has a poor blood supply, severe neurological symptoms may develop if TSS is not treated promptly. However, as it is rare, TSS is less often studied and its clinical features are often not recognized. METHODS: Between 2005 and 2012, 427 patients diagnosed with TSS underwent surgery in our department. The male to female ratio was 1.4:1. The mean age was 53 years. The most reported symptom was motor deficit in the lower extremities (347 cases, 81%), followed by sensory deficit in the lower limbs (271 cases, 64%). Falls were the most common trigger of acute symptoms (29 cases, 7%). Preoperative imaging results of each case were reviewed to summarize the causes and site of cord compression and coexisting spinal diseases. RESULTS: The most reported compressive factor was ossification of the ligamentum flavum (OLF), which implicated in 309 cases, followed by thoracic disk herniation (TDH) and ossification of the posterior longitudinal ligament (OPLL). The most common site of OLF and TDH was T9-L1 (56% and 89%, respectively), whereas OPLL was mainly found at T1-8 (90%). Forty-seven patients (11%) had coexisting lumbar spinal disease and 64 (15%) had cervical disease. CONCLUSIONS: Onset of TSS was generally insidious but may be triggered acutely by apparently trivial events. Myelopathy mainly affected the lower limbs. The most common cause was OLF in the lower thoracic spine. Cervical or lumbar spinal disease was often also evident; therefore, comprehensive clinical assessment is required to avoid delays in diagnosis and treatment.

Lumbar Disk Herniation in Children and Adolescents: The Significance of Configurations of the Lumbar Spine.

BACKGROUND: Lumbar disk herniation in adults is thought to be caused by repetitive overloading and age-rated degenerative changes. However, these causes are absent in children and adolescent patients. We assume that structural malformations in the lumbar spine could predispose intervertebral disks to early degeneration and hence need to be surgically fused. This issue has never been raised before. OBJECTIVE: To investigate the assumption that structural malformations in the lumbar spine could predispose intervertebral disks to early degeneration and hence need to be surgically fused. METHODS: Lumbar spine configurations, including the height of the intercrestal line, the length of L5 transverse processes, and the presence of transitional vertebrae, were recorded from anteroposterior radiographs taken from 63 consecutive pediatric patients with lumbar disk herniation admitted to our hospital over a period of 8 years. Each configuration was compared in relation to the level of disk herniation. Diskectomy alone was performed in 36 cases; arthrodesis was added in the remaining 27 cases. Patients' back and leg pain visual analog scale scores and frequency and their Oswestry Disability Index scores were recorded before surgery and at follow-up. The results were compared for assessment of outcome. RESULTS: Patients with high intercrestal lines and long L5 transverse processes had a significantly higher incidence of L4/5 disk herniation, whereas low intercrestal line and lumbarization were associated with L5/S1 disk herniation. Patients' visual analog scale scores, pain frequency, and Oswestry Disability Index score all improved significantly after surgery, but there was no significant difference with or without arthrodesis. CONCLUSION: Pediatric lumbar disk herniation is significantly associated with structural malformations of the lumbar spine, but arthrodesis does not improve the clinical outcome. ABBREVIATIONS: ICL, intercrestal lineLDH, lumbar disk herniationL5TP, L5 transverse processODI, Oswestry Disability IndexTV, transitional vertebraeVAS, visual analog scale.

[Analysis of risk factors for deep surgical site infection after posterior thoracic and lumbar surgery].

OBJECTIVE: To study the risk factors for deep surgical site infection after posterior thoracic and lumbar surgery. METHODS: The medical data of the patients with deep surgical site infection after posterior thoracic and lumbar surgery from January 2008 to December 2013 were reviewed.For each case patient, 3 non-infected controls were randomly selected from the same database of all patients who underwent posterior thoracic and lumbar surgery.Patients who had diagnosis of spinal fractures, infection, tuberculosis, and tumor were excluded. The microbiology and related factors were collected and analyzed. T-test, χ2 test and Logistic analysis were used to analyze the data, respectively. RESULTS: Ninety-nine cases were identified (infection group), 57 men and 42 women, average 54.5 years old, average body mass index 26.4 kg/m2. Fifty-five (55.6%) patients were identified with organisms, and the most common identified organism was Staphylococcus Aureus. Compared with the cases in the control group (44.4 g/L), the cases in the infection group (43.1 g/L) had a significant low albumin preoperatively (P=0.001). Multivariate Logistic analysis showed that obesity (OR=2.102, 95% CI=1.259-3.508), diabetes (OR=1.926, 95% CI=1.041-3.563), number of surgical levels≥3 (OR=1.985, 95% CI=1.130-3.486) were risk factors for this complication (P<0.05). CONCLUSION: For deep surgical site infection after posterior thoracic and lumbar surgery, obesity, diabetes, preoperative low albumin and number of surgical levels≥3 are risk factors.

Comparison between two types of "Scheuermann disease-like people": thoracolumbar disc herniation patients and healthy volunteers with radiological signs of Scheuermann's disease.

BACKGROUND: Scheuermann's disease (SD) is a spinal disorder and includes both a classic form and an atypical form. Interestingly, its existence among the general population as well as the disc disease patients is common. One of our previous studies showed that about 18% of the hospital staff members meet the SD criteria. On the other hand, another study has demonstrated that 95.2% of the symptomatic thoracolumbar disc herniation (STLDH) patients meet the SD criteria, which suggests that STLDH is very likely a special form of SD. The purpose of this study was to discriminate the factors contributing to the development of STLDH by comparing STLDH patients with the healthy SD-like hospital staff members. METHODS: This is a retrospective study including 33 STLDH patients who met the SD criteria and 30 SD-like hospital staff members. The STLDH group was chosen from a group of patients who underwent surgery after a diagnosis of STLDH (T10/11-L1/2) at our hospital between June 2007 and June 2010. SD-like hospital staff members were chosen from a database created in 2007, which contained a lumbar MR and low back pain (LBP) questionnaire of 188 hospital staff members. The demographic and radiologic characteristics were compared between groups. RESULTS: There was no statistical difference in sex, age, and height between the two groups. The STLDH patients had higher body weight, boby mass index, and thoracolumbar kyphotic angle than SD-like hospital staff members. In addition, STLDH patients had more levels of Schmorl's nodes (3.5±1.7 vs. 2.0±1.9, t = 3.364, P = 0.001) and irregular endplateson (4.0±1.9 vs. 2.7±1.9, t = 2.667, P = 0.010) compared to the SD-like hospital staff members. CONCLUSIONS: Higher body weight, higher body mass index, larger thoracolumbar kyphosis, and more Schmorl's nodes and irregular endplates on MR may be associated with the development of STLDH in "SD-like people."