Comparison of degenerative lumbar spondylolisthesis and isthmic lumbar spondylolisthesis: effect of pedicle screw placement on proximal facet invasion in surgical treatment.

BACKGROUND: Pedicle screw invasion of the proximal articular process will cause local articular process degeneration and acceleration, which is an important factor affecting adjacent segment degeneration. Although lumbar spondylolisthesis is a risk factor for screw invasion of the proximal joint, there is no clear conclusion regarding the two different types of spondylolisthesis. Therefore, the purpose of this study was to explore the influence of pedicle screw placement on proximal facet invasion in the treatment of degenerative spondylolisthesis and isthmic spondylolisthesis. METHODS: In total, 468 cases of lumbar spondylolisthesis treated by decompression and fusion in our hospital from January 2017 to January 2020 were included in this retrospective study. Among them, 238 cases were degenerative spondylolisthesis (group A), and 230 cases were isthmic spondylolisthesis (group B). Sex, age, body mass index, bone mineral density, preoperative visual analog scale (VAS) and Oswestry Disability Index (ODI) scores, postoperative VAS and ODI scores at 1 month and 3 months, and angle of the proximal facet joint at the last follow-up were recorded and compared between the two groups. The degree of pedicle screw invasion of the proximal facet joint was graded and compared by the SEO grading method. RESULTS: There were no significant differences in sex, age, body mass index, bone mineral density, preoperative VAS and ODI scores, or proximal facet joint angle between the two groups (P > 0.05). There was no significant difference in VAS and ODI scores between the two groups at 1 month and 3 months after the operation (P > 0.05). The VAS score of group A at the last follow-up was 1 (1,2). The VAS score of group B at the last follow-up was 3 (1,3). The ODI score of group A at the last follow-up was 6(4,26). The ODI score of group B at the last follow-up was 15(8,36). The VAS and ODI scores of the two groups at the last follow-up were significantly different (P < 0.05). According to the SEO grading method, the invasion of the proximal articular process by pedicle screw placement in group A involved 320 cases in grade 0, 128 cases in grade I and 28 cases in grade II. In group B, there were 116 cases in grade 0, 248 cases in grade I and 96 cases in grade II, with a significant difference (P < 0.01). CONCLUSION: In summary, a certain number of cases involving screws invading the proximal facet joint occurred in the two different types of lumbar spondylolisthesis, but the number in the isthmic spondylolisthesis group was significantly higher than that in the degenerative spondylolisthesis group, which caused more trauma to the proximal facet joint and significantly affected the patient prognosis.

Multivariate analysis of pedicle screw invasion of the proximal facet joint after lumbar surgery.

BACKGROUND: To analyze the risk factors for pedicle screw invasion of the proximal facet joint after lumbar surgery. METHODS: From January 2019 to January 2021, 1794 patients with lumbar degenerative disease, such as lumbar disc herniation, lumbar spinal stenosis and lumbar spondylolisthesis, were treated at our hospital. In all, 1221 cases were included. General data (sex, age, BMI), bone mineral density, proximal facet joint angle, degenerative lumbar spondylolisthesis, isthmic lumbar spondylolisthesis and fixed segment in the two groups were recorded. After the operation, vertebral CT of the corresponding surgical segments was performed for three-dimensional reconstruction and evaluation of whether the vertebral arch root screw interfered with the proximal facet joint. The included cases were divided into an invasion group and a noninvasion group. Univariate analysis was used to screen the risk factors for pedicle screw invasion of the proximal facet joint after lumbar surgery, and the selected risk factors were included in the logistic model for multivariate analysis. RESULTS: The single-factor analysis showed a significant difference in age, BMI, proximal facet joint angle, degenerative lumbar spondylolisthesis, and fixed segment (P < 0.1). Multifactor analysis of the logistic model showed a significant difference for age ≥ 50 years (P < 0.001, OR = 2.291), BMI > 28 kg/m2 (P < 0.001, OR = 2.548), degenerative lumbar spondylolisthesis (P < 0.001, OR = 2.187), gorge cleft lumbar relaxation (P < 0.001, OR = 2.410), proximal facet joint angle (35 ~ 45°: P < 0.001, OR = 3.151; > 45°: P < 0.001, OR = 3.578), and fixed segment (lower lumbar spine: P < 0.001, OR = 2.912). CONCLUSION: Age (≥ 50 years old), BMI (> 28 kg/m2), proximal facet joint angle (35 ~ 45°, > 45°), degenerative lumbar spondylolisthesis, isthmic lumbar spondylolisthesis and fixed segment (lower lumbar spine) are independent risk factors for pedicle screw invasion of the proximal facet joint after lumbar surgery. Compared with degenerative lumbar spondylolisthesis, facet joint intrusion is more likely in isthmic lumbar spondylolisthesis.

Risk factors for proximal junctional kyphosis after posterior long-segment internal fixation for chronic symptomatic osteoporotic thoracolumbar fractures with kyphosis.

BACKGROUND: This study aimed to analyze the risk factors for proximal junctional kyphosis (PJK) for patients with chronic symptomatic osteoporotic thoracolumbar fractures (CSOTLF) and kyphosis who underwent long-segment internal fixation. METHODS: We retrospectively reviewed the records of patients with CSOTLF complicated with kyphosis who underwent posterior multilevel internal fixation in our hospital between January 2013 and January 2020. The patients' age, sex, body mass index (BMI), bone mineral density (BMD), smoking status, cause of injury, comorbidities, injury segments, and American Spinal Injury Association (ASIA) grading non-surgical data; posterior ligament complex (PLC) injury, upper and lower instrumented vertebral position (UIV and LIV, respectively), number of fixed segments surgical data, proximal junctional angle (PJA), sagittal vertebral axis (SVA), pelvic incidence (PI), lumbar lordosis (LL), pelvic incidence-lumbar lordosis mismatch (PI-LL), pelvic tilt (PT), and sacral slope (SS) surgical indicators were collected. Patients were divided into postoperative PJK and non-PJK groups. RESULTS: This study included 90 patients; among them, 30 (31.58%) developed PJK postoperatively. All patients were followed up for > 24 months (mean 32.5 months). Univariate analysis showed significant differences in age, BMI, BMD, PLC injury, UIV, and LIV fixation position, number of fixation stages, and preoperative PJA, SVA, PI-LL, and SS between the two groups (P < 0.05). Additionally, no significant differences were observed in sex, smoking, cause of injury, complications, injury segment ASIA grade, and preoperative PT between the two groups (P > 0.05). Multifactorial logistic regression analysis showed that age > 70 years (OR = 32.279, P < 0.05), BMI > 28 kg/m2 (OR = 7.876, P < 0.05), BMD T value < - 3.5 SD (OR = 20.836, P < 0.05), PLC injury (OR = 13.981, P < 0.05), and preoperative PI-LL > 20° (OR = 13.301, P < 0.05) were risk factors for PJK after posterior long-segment internal fixation in elderly patients with CSOTLF complicated with kyphosis. CONCLUSION: CSOTLF patients undergoing posterior long segment internal fixation are prone to PJK, and age > 70 years, BMI > 28 kg/m2, BMD T value < - 3.5 SD, preoperative PI-LL > 20° and PLC injury may increase their risk.

When is the circumferential stabilization necessary for subaxial cervical fracture dislocations? The posterior ligament-bone injury classification and severity score: a novel treatment algorithm.

OBJECTIVE: To propose a novel classification and scoring system called the posterior ligament-bone injury classification and severity score (PLICS) that offers a quantitative score to guide the need for posterior stabilization in addition to anterior reconstruction for subaxial cervical fracture dislocations (SCFDs). METHODS: A total of 456 patients with SCFDs were prospectively included. Patients with PLICS ≥ 7 together with extremely unstable lateral mass fracture (EULMF) were classified as high-risk group, and the other patients were classified as low-risk group. For patients in the low-risk group, anterior-only reconstruction was performed; for patients in the high-risk group, additional posterior lateral mass fixation and fusion was performed after anterior reconstruction. Clinical outcome evaluation included using the visual analogue score (VAS), the Neck Disability Index (NDI), and the American Spinal Injury Association (ASIA) impairment scale. The change in the local sagittal alignment kyphosis Cobb angle was also recorded. RESULTS: A total of 370 patients (81.1%) completed the minimal 12-month follow-ups, including 321 patients of low-risk group and 49 patients of high-risk group. Compared with the average VAS score preoperatively, the score at 12-month follow-up was significantly improved (from 6.1 + 0.3 to 1.1 + 0.2 in the low-risk group, P < 0.001; from 6.4 + 0.2 to 1.4 + 0.2 in the high-risk group, P < 0.001). The average NDI score at the 12-month follow-up was statistically low in the low-risk group (8.8 + 2.5 vs 13.8 + 3.4, P = 0.034). At least more than one grade improvement in the ASIA scale was observed in 80.5% of all patients. The local kyphosis Cobb angle at the injured segment averaged improved in both groups. CONCLUSION: A PLICS score ≥ 7 together with EULMF can be the threshold for posterior stabilization in addition to anterior reconstruction for the patients with SCFDs.

Comparison of robot-assisted and freehand pedicle screw placement for lumbar revision surgery.

BACKGROUND: The accuracy of robot-assisted pedicle screw implantation is a safe and effective method in lumbar surgery, but it still remains controversial in lumbar revision surgery. This study evaluated the clinical safety and accuracy of robot-assisted versus freehand pedicle screw implantation in lumbar revision surgery. METHODS: This was a retrospective study. From January 2018 to December 2019, 81 patients underwent posterior lumbar revision surgery in our hospital. Among them, 39 patients underwent revision surgery performed with robot-assisted pedicle screw implantation (Renaissance robotic system), whereas the remaining 42 patients underwent traditional freehand pedicle screw implantation. All patients underwent magnetic resonance imaging (MRI), computed tomography (CT), and X-ray before revision surgery. The sex, age, body mass index, bone mineral density, operative time, blood loss, operative segments, intra-operative fluoroscopy time, and complications were compared between the two groups. The accuracy of pedicle screw implantation was measured on CT scans based on Gertzbein Robbins grading, and the invasion of superior level facet joint was evaluated by Babu's method. RESULTS: There was no statistical difference about the baseline between the two groups (P > 0.05). Although there were no significant differences in operative time and complications between the two groups (P > 0.05), the robot-assisted group had significantly less intra-operative blood loss and shorter intra-operative fluoroscopy times than the freehand group (P < 0.05). In the robot-assisted group, a total of 267 screws were inserted, which were marked as grade A in 250, grade B in 13, grade C in four, and no grade D or E in any screw. In terms of invasion of superior level facet joint, a total of 78 screws were inserted in the robot-assisted group, which were marked as grade 0 in 73, grade 1 in four, grade 2 in one, and grade 3 in zero. By comparison, 288 screws were placed in total in the freehand group, which were rated as grade A in 251, grade B in 28, grade C in eight, grade D in one, and no grade E in any screw. A total of 82 superior level facet joint screws were inserted in freehand group, which were marked as grade 0 in 62, grade one in 18, grade 2 in two, and grade 3 in zero. The robot-assisted technique was statistically superior to the freehand method in the accuracy of screw placement (P < 0.05). CONCLUSION: Compared with freehand screw implantation, in lumbar revision surgery, the Renaissance robot had higher accuracy and safety of pedicle screw implantation, fewer superior level facet joint violations, and less intra-operative blood loss and intra-operative fluoroscopy time.

Is laminectomy and fusion the better choice than laminoplasty for multilevel cervical myelopathy with signal changes on magnetic resonance imaging? A comparison of two posterior surgeries.

BACKGROUND: This study aimed to compare the clinical outcomes and complications between laminectomy and fusion (LF) and laminoplasty (LP) for multi-level cervical spondylotic myelopathy (MCSM) with increased signal intensity (ISI) on T2-weighted images (T2WI). METHODS: In this retrospective cohort study, we analyzed 52 patients with MCSM with ISI on T2WI who underwent laminoplasty (LP group). The Japanese Orthopedic Association (JOA) score, the Visual Analogue Scale (VAS) score, the physical and mental component scores (PCS and MCS) of Short-Form 36 (SF-36), and the extension and flexion ranges of motion (ROMs) were recorded. As controls, propensity score matching identified 52 patients who underwent laminectomy and fusion (LF group) from January 2014 to June 2016 using 7 independent variables (preoperation): age, sex, JOA score, SF-36 PCS, SF-36 MCS, preoperative symptom duration and high signal intensity ratio (HSIR). RESULTS: The operative duration in the LF group was significantly higher than that in the LP group. At the last follow-up, the JOA score, VAS score, and SF-36 (PCS and MCS) scores were all significantly improved in both groups. The extension and flexion ROMs were decreased in both groups but significantly better in the LP group than in the LF group. Both groups demonstrated similar clinical improvements at the final follow-up. The complication rate was higher in the LF group. CONCLUSION: The present study demonstrates that LP for MCSM with ISI on T2WI achieves similar clinical improvement as LF. However, longer operative durations, higher complication rates and lower extension and flexion ROMs were found in the LF group.

Accuracy of Robot-Assisted Percutaneous Pedicle Screw Placement for Treatment of Lumbar Spondylolisthesis: A Comparative Cohort Study.

BACKGROUND With the in-depth development of minimally invasive spine surgery in recent years, robot- and computer-assisted technologies have been increasingly used and successfully applied to spinal surgery. MATERIAL AND METHODS We performed a retrospective analysis of 60 patients with grade I or II lumbar spondylolisthesis who underwent minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) from January 2017 to December 2017. A robot-assisted surgical system was used in 30 patients for pedicle screw placement. The other 30 patients underwent fluoroscopy-guided percutaneous pedicle screw placement. RESULTS There were 130 screws placed under fluoroscopic guidance, with 26.2% penetration of the pedicle wall. There were 130 screws placed in robotic-assisted surgery, with 6.2% penetration of the pedicle wall. Severe screw deviation (Neo grade III) was identified in 4 screws in the fluoroscopy-guided group, while no severe deviation was noted in the robot-assisted group. In the fluoroscopic group, 15.6% of screws penetrated the superior articular process, and 2.1% screws had severe complications (Babu grade III). However, only 5.1% of screws in the robot-assisted group had severe complications. The mean screw insertion angle was significantly greater in the robot-assisted group than in the fluoroscopy-guided group (23.8±6.1° vs. 18.4±7.2°, P=0.017). CONCLUSIONS Compared to fluoroscopy-guided percutaneous pedicle screw placement, robot-assisted percutaneous pedicle screw placement has the following advantages: greater accuracy, lower incidences of screw penetration of the pedicle wall and invasion of the facet joints, and better screw insertion angle. Combined with MIS-TLIF, robot-assisted percutaneous pedicle screw placement is an effective minimally invasive treatment for lumbar spondylolisthesis.

Suboccipital neuralgia after C1 pedicle screw insertion: do we neglect atlantooccipital joint violation? - Case report and literature review.

BACKGROUND: Occipital neuralgia is one of the postoperative complications of C1 lateral mass screw insertion, which was deemed to be related with the C2 nerve root dysfunction. CASE PRESENTATION: A 52-year-old female patient presented with gradually progressive numbness and weakness in her extremities for 6 months. X-ray and computed tomography (CT) scan revealed obvious anterior atlantoaxial dislocation (ADD), which was reducible on extensive view. Atlantoaxial pedicle screw fixation and bone graft was performed. Immediately after the operation, the neurological symptom significantly improved. The patient complained of restricted cervical rotation and suboccipital neuralgia which was exacerbated by rotation with an intensity of 7 on a visual analog scale (VAS) ranging from 0 to 10 at postoperative day 5. While a satisfactory reduction was detected in the postoperative CT, violation of the left atlantooccipital joint was observed in the left C1 screw. Nimesulide (daily dosage of 0.2 g) and bracing were recommended immediately. At the 2 month follow-up, both the neurological improvement and reduction were maintained. The VAS of suboccipital neuralgia is 3 and decreased to 1 at 6 months postoperative. Bony fusion of the left atlantooccipital joint was confirmed by CT scan at 6 months postoperative. The patient complained that the suboccipital neuralgia was tolerable without the assistance of braces or medications for pain. At the 18 month follow-up, only stiffness of head flexion and rotation was observed without suboccipital neuralgia. CONCLUSION: Suboccipital neuralgia after atlantooccipital joint violation of C1 pedicle screw placement most likely results from C1 nerve root irritation. As the corresponding dermatome differs from the distributing region and aggravated factor of C2 nerve root dysfunction, neuralgia due to C1 irritation was only localized at suboccipital region and exacerbated by rotation.

Acute massive cerebellar infarction associated with craniocervical junction complex malformation: a case report and literature review.

We report a case of acute massive cerebellar infarction associated with craniocervical junction (CVJ) complex malformation in a 21-year-old male. Timely surgical intervention prevented the deterioration of his neurological status.

Transoral anterior release, odontoid partial resection, and reduction with posterior fusion for the treatment of irreducible atlantoaxial dislocation caused by odontoid fracture malunion.

PURPOSE: Several techniques have been introduced to manage irreducible atlantoaxial dislocation (IAAD). However, no study has reported the surgical method for the management of IAAD caused by odontoid fracture malunion. This study aimed to introduce a surgical method of transoral anterior release, odontoid partial resection, and reduction with sequential posterior fusion for the treatment of IAAD caused by odontoid fracture malunion. We also evaluated the clinical efficacy of this surgery. METHODS: This study included seven cases of IAAD caused by odontoid fracture malunion, collected from January 2008 to January 2011. Anterior atlantoaxial release was performed through anterior transoral approach, followed by partial resection of the odontoid process. C1-C2 were then fixed through pedicle screws and rods, and then fused posteriorly by single stage. Neurologic status was evaluated using the Japanese Orthopaedic Association (JOA) scoring system. RESULTS: All seven patients had complete release, and satisfactory reduction. Bony fusion was seen in all patients postoperatively. The patients were followed up for an average of 19.6 months (ranged from 9 to 36 months). The average of patients JOA scores at the final follow-up was significantly higher than that of their preoperative scores. Furthermore, the average improvement in neurological function was 87.4 %. No screw loosening, implant migration or implant failures, atlantoaxial redislocation, or signs of instability were observed in any of the patients during the follow-up period. CONCLUSIONS: Transoral anterior release, odontoid partial resection, and reduction combined with posterior fusion are effective, reliable, and safe procedures for the treatment of IAAD caused by odontoid fracture malunion.

Surgical treatment of scoliosis associated with syringomyelia with no or minor neurologic symptom.

PURPOSE: Syringomyelia with coexisting intraspinal abnormities is thought to increase the risk of neurologic injury during surgical correction of the scoliosis. However, surgical treatment for intraspinal abnormities carries significant morbidity risks including worsening neurological function and wound complications. The authors' aim in this study was to evaluate one-stage posterior correction of scoliosis in this patient population without prophylactic surgical treatment for neural axis malformations before scoliosis correction. METHODS: A total of 29 patients with syringomyelia and coexisting intraspinal abnormities who underwent scoliosis correction were evaluated. The average age was 15.6 years (range 12-23). All patients were examined for neural axis abnormalities using MRI, including syringomyelia with Chiari I malformation in 18 patients, syringomyelia with tethered cord and/or diastematomyelia in 11. None of patients presented with symptoms suggesting significant neurological dysfunction. The surgical efficacies and complications of correction were reviewed. RESULTS: The preoperative Cobb angle of major coronal curve averaged 65° (range 46°-95°), and it measured 28° (range 22°-43°) at the last follow-up, for a 63 % correction. Maximal kyphosis averaged 52° (range 41°-69°) preoperatively, and improved to 29° (range 22°-43°) at ultimate follow-up, for a 46 % correction. The average follow-up was 6 years (4-8 years). None of the patients experienced deterioration in their neurologic status. CONCLUSION: The study results suggested that prophylactic neurosurgery for intraspinal abnormality may be unnecessary in patients with asymptomatic or minor symptomatic syringomyelia and coexisting intraspinal abnormities. One-stage posterior correction of scoliosis in this patient population does not involve significant complications and seems to be an alternative and safe treatment option.

Roles of p38 MAPK signalling in intervertebral disc degeneration.

Intervertebral disc degeneration (IVDD) is a common degenerative disease mediated by multiple factors. Because of its complex aetiology and pathology, no specific molecular mechanisms have yet been identified and no definitive treatments are currently available for IVDD. p38 mitogen-activated protein kinase (MAPK) signalling, part of the serine and threonine (Ser/Thr) protein kinases family, is associated with the progression of IVDD, by mediating the inflammatory response, increasing extracellular matrix (ECM) degradation, promoting cell apoptosis and senescence and suppressing cell proliferation and autophagy. Meanwhile, the inhibition of p38 MAPK signalling has a significant effect on IVDD treatment. In this review, we first summarize the regulation of p38 MAPK signalling and then highlight the changes in the expression of p38 MAPK signalling and their impact on pathological process of IVDD. Moreover, we discuss the current applications and future prospects of p38 MAPK as a therapeutic target for IVDD treatment.

Does the Choice of Operative Side Affect the Clinical Outcome of Unilateral Percutaneous Kyphoplasty for Osteoporotic Vertebral Compression Fracture?

BACKGROUND: Studies have found that the rate of improvement in pain after percutaneous kyphoplasty (PKP) is 49% to 90%, and there are still some patients who may continue to sustain intractable back pain after surgery. OBJECTIVES: To compare the clinical efficacy and imaging results between unilateral PKP performed from the symptom-dominating side and the non-dominating side in OVCF treatment. STUDY DESIGN: Prospective study. SETTING: All data were from Honghui Hospital in Xi'an. METHODS: One hundred forty-two patients of osteoporotic vertebral compression fracture (OVCF) treated with unilateral PKP were eventually recruited and randomly assigned to either the A or B group. Patients in group A received PKP from the symptom-dominating side; patients in group B received PKP from the symptom non-dominating side. The demographic characteristics, related surgical information, and complications observed within both groups were recorded. The clinical outcomes evaluation included the visual analog scale (VAS) score for low back pain and the Oswestry Disability Index (ODI). Evaluation of imaging results included anterior height (AH), kyphosis angulation (KA), and contralateral distribution rate of bone cement. RESULTS: One hundred eighteen patients (48 men and 70 women; age range: 60-83 years), including 59 patients in the A group and 59 patients in the B group, were available for the complete assessment. There were 5 cases and 7 cases of bone cement leakage in groups A and B, respectively, which were asymptomatic para-vertebral or inter-vertebral leakage without intra-spinal leakage. Compared with the preoperative data, significant improvements in the VAS scores and ODI were observed at each follow-up interval. The VAS score and ODI in the A group were significantly lower than in the B group only within 2 months (P < 0.05). Compared with the preoperative data, the AH and KA in the 2 groups were improved (P < 0.05). There was no significant difference in AH and KA between the 2 groups at each follow-up interval (P > 0.05). LIMITATIONS: A single-center study. CONCLUSIONS: The unilateral PKP performed via the symptom-dominating side can effectively relieve back pain and improve the patient's quality of life at the early stage.

Risk Factors for New Vertebral Fracture After Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fractures.

PURPOSE: To analyze the risk factors for new vertebral fractures after percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fractures (OVCFs). PATIENTS AND METHODS: We retrospectively reviewed the records of patients with symptomatic OVCFs who underwent PVP in our hospital, from January 2014 to January 2019. Demographic and lifestyle data on the presence of underlying chronic disease, preoperative bone mineral density, details of vertebral fractures, postoperative osteoporosis treatment, and new fracture development were collected. Patients were divided into postoperative fracture and non-fracture groups. To identify the independent risk factors for new vertebral fracture development, variables significant on univariate analysis were included in a multivariate regression model. RESULTS: Of the 2202 patients treated with PVP, 362 (16.43%) had a new postoperative vertebral fracture. All patients were followed up for >12 months (mean 14.7 months). Univariate analysis revealed no significant difference in height; body weight; preoperative bone mineral density; number of fractured vertebrae; injection volume of bone cement in a single vertebra; leakage rate of bone cement; or presence of hypertension, coronary heart disease, and chronic obstructive pulmonary disease between the fracture and non-fracture groups (P>0.05). Age, sex, smoking, alcohol consumption, diabetes mellitus, postoperative exercise, and postoperative osteoporosis treatment were associated with new vertebral fractures (all P<0.05). A multivariate analysis showed that age (odds ratio [OR]=1.212, P<0.0001), female sex (OR=1.917, P<0.0001), smoking (OR=1.538, P=0.026), and diabetes (OR=1.915, P<0.0001) were positively correlated with new vertebral fracture development, whereas postoperative exercise (OR=0.220, P<0.0001) and osteoporosis treatment (OR=0.413, P<0.0001) were negatively correlated. CONCLUSION: Elderly patients, females, and those with a history of smoking and diabetes are at high risk of new vertebral fracture after PVP. Patients should be encouraged to stop smoking and consuming alcohol, control blood glucose level, participate in sufficient physical activity, and adhere to osteoporosis treatment to prevent new vertebral fractures.

Posterior Ligament-Bone Injury Classification and Severity Score: A Novel Approach to Predict the Failure of Anterior-only Surgery for Subaxial Cervical Facet Dislocations.

STUDY DESIGN: Clinical case series. OBJECTIVE: The aim of this study was to propose a novel posterior ligament-bone injury classification and severity (PLICS) score system that can be used to reflect the severity of subaxial cervical fracture dislocations (SCFDs) and predict the failure of anterior-only surgery; and to measure the intraobserver and interobserver reliability of this system. SUMMARY OF BACKGROUND DATA: The approach selection for SCFDs is controversial. Although the anterior approach is familiar for most surgeons, postoperative hardware failure and/or delayed cervical deformity is a nonnegligible complication. METHODS: Ten patients were randomly selected for intraobserver reliability evaluation on two separate occasions, one month apart. Another 30 patients were randomly selected, and the interobserver reliability was measured by comparing results of each case between each reviewer and averaging. To analyze the difference in the PLICS score, 354 patients fulfilled the follow-up were divided into stable and unstable groups according to whether radiologically stable was observed during follow-up. RESULTS: For the intraobserver reliability, the mean intraclass correlation coefficient for the 10 reviewers was 0.931. For the interobserver reliability, the mean interobserver correlation coefficient for the three elements was 0.863. Among 16 patients with PLICS score ≥7, two patients in the stable group manifested with severe injury of the posterior ligamentous complex (PLC); extremely unstable lateral mass fractures with or without severe injury of PLC were detected in the 14 patients of the unstable group. CONCLUSION: The proposed PLICS score system showed excellent intraobserver and interobserver reliability. When a PLICS score is >7 or 7 accompanied by extremely unstable lateral mass fractures, the risk of postoperative failure after an anterior-only reconstruction is high and supplemental posterior strengthening can be considered.Level of Evidence: 4.

Cocktail Treatment with a Gelatin Sponge Impregnated with Ropivacaine, Dexamethasone, and Vitamin B12 Promotes Early Postoperative Recovery after Percutaneous Endoscopic Lumbar Discectomy: A Retrospective, Case-Controlled Study.

BACKGROUND: Percutaneous endoscopic lumbar discectomy (PELD) can only relieve mechanical compression but cannot directly reduce the inflammatory reaction of the adjacent nerve root, which contributes to persistent pain and physical disabilities postoperatively. Numerous studies have explored the application of epidural steroids after an open lumbar discectomy in relieving pain by reducing local inflammatory reactions and further peridural scar formation. OBJECTIVES: To explore that whether "cocktail treatment" in which a gelatin sponge was impregnated with ropivacaine, dexamethasone, and vitamin B12 promoted early postoperative recovery after PELD. STUDY DESIGN: Retrospective, case-controlled study. SETTING: All data were from Hong-Hui Hospital in Xi'an. METHODS: Between January 2016 and January 2017, 100 patients of single-level lumbar disc herniation were treated with PELD in our hospitals. The cocktail treatment was applied in the first 50 patients (group cocktail), and an equal size gelatin sponge without drugs was used in the other 50 patients as control (group noncocktail). The clinical outcome evaluation included the Visual Analog Scale (VAS) score for back and leg pain and Oswestry Disability Index (ODI) score. RESULTS: There was a significant difference in the mean periods of return to work (4.25 ± 1.88 weeks in the cocktail group and 5.18 ± 2.19 weeks in the noncocktail group) (P < 0.01). Compared with the preoperative data, a significant improvement in VAS scores of back pain and sciatica and ODI were observed in each follow-up interval (P < 0.05, respectively). In the noncocktail group, there were visible fluctuations in the 3 indicators within the first week after surgery. This phenomenon was not observed in the cocktail group, a difference that was statistically significant (P < 0.05, respectively). In further follow-up, no significant differences were observed between the 2 groups (P > 0.05, respectively). LIMITATIONS: The nonrandomized, single-center, retrospective design is a major limitation of this study. CONCLUSIONS: The "cocktail treatment" with a gelatin sponge impregnated with ropivacaine, dexamethasone, and vitamin B12 promotes early and satisfactory back and leg pain relief and fast functional recovery after PELD. KEY WORDS: Endoscopic lumbar discectomy, lumbar disc herniation, steroids, nerve root block, gelatin sponge.

Safety and Efficacy of Hydrogen Peroxide in Controlling Blood Loss and Surgical Site Infection After Multisegmental Lumbar Spine Surgery: A Retrospective, Case-Controlled Study.

OBJECTIVE: To explore the safety and efficacy of hydrogen peroxide H2O2 in controlling blood loss and surgical site infection (SSI) after multisegmental lumbar spine surgery. METHODS: A total of 2626 patients who had undergone multisegmental lumbar spinal surgery from January 2015 to January 2018 were included in the present study. Stratified by the use of H2O2 irrigation, they were divided into 2 groups: the control group (n = 1345) and the experimental group (n = 1281). The demographic parameters, laboratory examination results, and surgery-related information (e.g., operative time, number of operated levels, intraoperative blood loss, postoperative drainage, postoperative SSI, extubation time), and perioperative complications were recorded. RESULTS: No significant differences were seen regarding the demographic parameters, laboratory examination results, comorbidities, and surgery-related information. The extubation time and postoperative drainage collection were lower in the experimental group (3.6 ± 0.5 vs. 4.1 ± 0.6 days, P = 0.402; 251.8 ± 67.5 vs. 291.8 ± 71.3 mL, P = 0.013). In the control group, the rate of SSI was 2.4% (32 of 1345) and included 17 superficial wound infections and 15 deep wound infections. In the experimental group, the SSI rate was 1.4% (18 of 1281; 15 with a superficial wound infection and 3 with a deep wound infection). Staphylococcus aureus was the most common organism, especially in the experimental group (66.7% vs. 50%). No statistically significant difference was found between the 2 groups in the perioperative complications, including hematencephalon, deep vein thrombosis, pulmonary embolism, and myocardial infarction (P > 0.05). Pneumocephalus was not observed in either group. CONCLUSION: The application of H2O2 in posterior lumbar interbody fusion can reduce the blood loss and incidence of SSI after surgery and was quite beneficial for controlling the increasing number of vancomycin-resistant bacteria.

Can Posterior Ligament Structure Be Functionally Healed After Anterior Reduction and Fusion Surgery in Patients with Traumatic Subaxial Cervical Fracture-Dislocations?

BACKGROUND: Selection of approach for subaxial cervical fracture-dislocation (SCFD) is controversial. The questions of whether a posterior ligamentous structure (PLS) can be functionally healed in patients with SCFD and how long this healing process takes are critical in these patients. METHODS: This study retrospectively enrolled 394 patients with SCFD who underwent anterior decompression, reduction, and fusion between January 2002 and December 2017. The definition of functional healing of PLS was based on evaluations of clinical function and radiographic stability of PLS. RESULTS: Follow-up was available for 354 patients (89.8%). The PLS of 339 cases was functionally healed at the first follow-up interval without any posterior surgical intervention. No hardware failure or progressive cervical kyphosis was observed at further follow-up. At 12 months postoperatively, interbody fusion was satisfactory. However, the other 15 patients experienced nonhealing PLS at 8 weeks postoperatively and developed cervical deformity at further follow-up. Five patients refused revision surgery; the other 10 patients obtained solid fusion after revision surgeries. CONCLUSIONS: Among 354 patients with SCFD and treated by single anterior reduction and fixation, simple PLS injury without any bony instability at the posterior column of the cervical spine can be functionally healed in 95.8% of patients by external fixation for 8 weeks. Whether this finding is applicable to various types of SCFD should be verified in further prospective studies with larger samples.

Can Zero-Profile Cage Maintain the Cervical Curvature Similar to Plate-Cage Construct for Single-Level Anterior Cervical Diskectomy and Fusion?

OBJECTIVE: We sought to compare the clinical and radiologic outcomes after anterior cervical surgery between zero-profile (Zero-P) cage and plate-cage construct (PCC). METHODS: One-hundred and sixteen patients with single-level cervical disk herniation who underwent anterior cervical diskectomy and fusion between May 2015 and March 2017 were enrolled. They were divided into a Zero-P group (61 cases) and a PCC group (55 cases). At 1, 6, 12, and 24 months after the operation, routine follow-up evaluation was recommended including visual analog scale score and Japanese Orthopaedic Association score. The lateral x-ray film was performed at 1 and 24 months postoperatively. RESULTS: All 116 patients successfully completed the operation and achieved bone fusion. While there was no significant difference in the amount of bleeding between the 2 groups, the operation time of the Zero-P group was significantly shorter than that of the PCC group with statistically difference. The visual analog scale score and Japanese Orthopaedic Association score of the 2 groups at each follow-up interval postoperatively were significantly improved compared with that before operation; the difference was statistically significant (P < 0.05, respectively). While all the C2-7 cervical curvature, segmental Cobb angle, and height of adjacent vertebral body were lost at the 24-month follow-up, the significant difference was observed in the Zero-P group (P < 0.05, respectively). CONCLUSIONS: Compared with the Zero-P system, the PCC system provides a comparable clinical outcome. Although it showed the disadvantages in controlling the operation time and surgical bleeding, the radiologic outcome was better at the 2-year follow-up.

Epidemiological characteristics of spinal cord injury in Northwest China: a single hospital-based study.

BACKGROUND: While the cities in China in which spinal cord injury (SCI) studies have been conducted previously are at the forefront of medical care, northwest China is relatively underdeveloped economically, and the epidemiological characteristics of SCI have rarely been reported in this region. METHODS: The SCI epidemiological survey software developed was used to analyze the data of patients treated with SCI from 2014 to 2018. The sociodemographic characteristics of patients, including name, age, sex, and occupation, were recorded. The following medical record data, obtained from physical and radiographic examinations, were included in the study: data on the cause of injury, fracture location, associated injuries, and level of injury. Neurological function was evaluated using the American Spinal Injury Association (ASIA) impairment scale. In addition, the treatment and complications during hospitalization were documented. RESULTS: A total of 3487 patients with SCI with a mean age of 39.5 ± 11.2 years were identified in this study, and the male to female ratio was 2.57:1. The primary cause of SCI was falls (low falls 47.75%, high falls 37.31%), followed by traffic accidents (8.98%), and impact with falling objects (4.39%). Of all patients, 1786 patients (51.22%) had complications and other injuries. According to the ASIA impairment scale, the numbers of grade A, B, C, and D injuries were 747 (21.42%), 688 (19.73%), 618 (17.72%), and 1434 (41.12%), respectively. During the hospitalization period, a total of 1341 patients experienced complications, with a percentage of 38.46%. Among all complications, pulmonary infection was the most common (437, 32.59%), followed by hyponatremia (326, 24.31%), bedsores (219, 16.33%), urinary tract infection (168, 12.53%), deep venous thrombosis (157, 11.71%), and others (34, 2.53%). Notably, among 3487 patients with SCI, only 528 patients (15.14%) received long-term rehabilitation treatment. CONCLUSION: The incidence of SCI in northwest China was on the rise with higher proportion in males; fall and the MCVs were the primary causes of SCI. The occupations most threatened by SCI are farmers and workers. The investigation and analysis of the epidemiological characteristics of SCI in respiratory complications are important factors leading to death after SCI, especially when the SCI occurs in the cervical spinal cord. Finally, the significance of SCI rehabilitation should be addressed.