Does minimally invasive fusion technique influence surgical outcomes in isthmic spondylolisthesis?

OBJECTIVE: To compare the clinical and radiographic results between open transforaminal interbody fusion (TLIF-O) and minimally invasive TLIF (TLIF-M) for single-level low grade isthmic spondylolisthesis (IS). METHODS: This study enrolled 45 patients who underwent single-level TLIF with low grade IS. The patients were divided into two groups according to operative method: TLIF-M (20 patients) and TLIF-O (25 patients). TLIF-O group was matched with TLIF-M. RESULTS: At one-year postoperatively, there were no significant differences in any radiologic parameters between the two groups. Perioperative results such as blood loss, operation time, and hospital stay were superior in TLIF-M than in TLIF-O. Fusion was achieved in 17 of 20 patients (85.0%) in TLIF-M and 23 of 25 (92.0%) patients in TLIF-O. Back Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores of TLIF-O were significantly lower than TLIF-M at one (back VAS, ODI) and six months (ODI) postoperatively. CONCLUSIONS: TLIF-M and TLIF-O produced similar clinical and radiological outcomes, including reduction of spondylolisthesis and disc space height restoration at one-year follow-up for single-level low grade IS. However, considering perioperative outcomes, back pain, and quality of life, TLIF-M might be a better option for single-level low grade IS compared to TLIF-O.

Herniated Discs at the Cervicothoracic Junction.

BACKGROUND: Disc herniations at the cervicothoracic junction (C7-T1 level) are unusual, and there have only been a few studies of patients with herniated C7-T1 discs. In addition, previous studies did not focus on the mechanism and causes of solitary cervicothoracic junction disc herniation. The authors investigated the characteristics, symptom duration, clinical course, and biomechanics of cervicothoracic junction disc herniation by comparing patients with C7-T1 disc herniation (C7-T1 group) with control groups. METHODS: Thirty-six patients who underwent solitary C7-T1 single-level disc surgery between 2006 and 2015 were included. For radiographic comparison, patients in a herniated C5-C6 disc group and the healthy control group were cohort matched. RESULTS: In the C7-T1 group, the disc herniation mainly occurred in the foraminal space (P < 0.0001). The C7-T1 group was significantly associated with a history of trauma (P < 0.0001). In addition, the cervical vertebral body was more readily observed on plain lateral radiographs in the C7-T1 group (7.36 ± 0.068). Patients in the C5-C6 group tended to have the sternal notch more frequently located above the T2-T3 disc space than other groups (P = 0.014). CONCLUSIONS: C7-T1 disc herniation demonstrates unique characteristics. Understanding the features of disc herniation at the cervicothoracic junction would be helpful for optimal care.

The Clinical Significance of Lumbosacral Transitional Vertebrae on the Surgical Outcomes of Lumbar Discectomy: A Retrospective Cohort Study of Young Adults.

OBJECTIVE: To evaluate whether the presence of lumbosacral transitional vertebrae (LSTV) affects the clinical outcomes of microdiscectomy (MD) in young adults with lumbar disc herniation. METHODS: We retrospectively included 398 patients who were followed-up for at least 2 years after MD for lumbar disc herniation at L4/5 (disc above the LSTV). The patients were divided into 2 groups. Group A was made up of 31 patients in whom LSTV was detected. Group B, in contrast, was made up of 35 patients in whom LSTV was not detected. The LSTV were classified using plain radiographs and three-dimensional computed tomography by Castellvi et al. The primary outcome measure was pain intensity at each follow-up visit assessed with visual analog scale for back and leg. Secondary outcome measures included the Oswestry Disability Index, a 12-item short-form health survey for quality of life, complications, and recurrence rate. RESULTS: After surgery, the visual analog scale scores for the back and leg decreased significantly in both groups. However, the back pain intensity in group A worsened at 12 and 24 months postoperatively. The Oswestry Disability Index scores and 12-item short-form health survey (both mental and physical) worsened at 12 and 24 months postoperatively in group A. Two cases of reherniation (6.5 %) were observed in group A, who required reoperation. CONCLUSIONS: LSTV can limit a patient's clinical improvement after MD with regard to pain intensity and recurrence. Caution must be taken when a patient is scheduled to undergo surgery.

WITHDRAWN: Characteristics of patients with herniated discs at the cervicothoracic junction.

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Radiologic Findings and Risk Factors of Adjacent Segment Degeneration after Anterior Cervical Discectomy and Fusion : A Retrospective Matched Cohort Study with 3-Year Follow-Up Using MRI.

OBJECTIVE: The purpose of this study was to figure out the radiologic findings and risk factors related to adjacent segment degeneration (ASD) after anterior cervical discectomy and fusion (ACDF) using 3-year follow-up radiography, computed tomography (CT), and magnetic resonance image (MRI). METHODS: A retrospective matched comparative study was performed for 64 patients who underwent single-level ACDF with a cage and plate. Radiologic parameters, including upper segment range of motion (USROM), lower segment range of motion (LSROM), upper segment disc height (UDH), and lower segment disc height (LDH), clinical outcomes assessed with neck and arm visual analogue scale (VAS), and risk factors were analyzed. RESULTS: Patients were categorized into the ASD (32 patients) and non-ASD (32 patients) group. The decrease of UDH was significantly greater in the ASD group at each follow-up visit. At 36 months postoperatively, the difference for USROM value from the preoperative one significantly increased in the ASD group than non-ASD group. Preoperative other segment degeneration was significantly associated with the increased incidence of ASD at 36 months. However, pain intensity for the neck and arm was not significantly different between groups at any post-operative follow-up visit. CONCLUSION: The main factor affecting ASD is preoperative other segment degeneration out of the adjacent segment. In addition, patients over the age of 50 are at higher risk of developing ASD. Although there was definite radiologic degeneration in the ASD group, no significant difference was observed between the ASD and non-ASD groups in terms of the incidence of symptomatic disease.

Paraspinal muscle, facet joint, and disc problems: risk factors for adjacent segment degeneration after lumbar fusion.

BACKGROUND CONTEXT: Adjacent segment degeneration (ASD) is one of the major complications after lumbar fusion. Several studies have evaluated the risk factors of ASD. Although the paraspinal muscles play an important role in spine stability, no study has assessed the relationship between paraspinal muscle atrophy and the incidence of ASD after lumbar fusion. PURPOSE: In the present study, we aimed to verify the known risk factors of ASD, such as body mass index (BMI), preoperative adjacent facet joint degeneration, and disc degeneration, and to assess the relationship between paraspinal muscle atrophy and ASD. STUDY DESIGN: This is a retrospective 1:1 pair analysis matched by age, sex, fusion level, and follow-up period. PATIENT SAMPLE: To calculate the appropriate sample size for the study, we performed a pre-study analysis of the paraspinal muscle cross-sectional area (CSA), and estimated that at least 35 cases would be needed for each group. Among the 510 patients who underwent posterior lumbar fusion for degenerative lumbar disease between January 2009 and October 2009, a total of 50 patients with ASD after surgery were selected. Another group of 50 matched patients with degenerative lumbar disease without ASD after spinal fusion were selected as the control group. Each patient in the ASD group was matched with a control patient according to age, sex, fusion level, and follow-up period. OUTCOME MEASURES: Radiographic measurements and demographic data were reviewed. METHODS: The risk factors considered were higher BMI, preoperative adjacent segment disc and facet degeneration, and preoperative paraspinal muscle atrophy and fatty degeneration. The radiographic data were compared between the ASD and control groups to determine the predictive factors of ASD after posterior lumbar fusion by using logistic regression analysis. The study was not externally funded. The authors have no conflict of interest to declare. RESULTS: Multivariate logistic regression analysis indicated that higher BMI (odds ratio [OR]: 1.353, p=.008), preoperative facet degeneration on computed tomography examination (OR: 3.075, p=.011), disc degeneration on magnetic resonance imaging (MRI) (OR: 2.783, p=.003), fatty degeneration (OR: 1.080, p=.044), and a smaller relative CSA of the paraspinal muscle preoperatively (OR: 0.083, p=.003) were significant factors for predicting the development of ASD. CONCLUSIONS: The occurrence of radiological ASD is most likely multifactorial, and is associated with a higher BMI, preexisting facet and disc degeneration on preoperative examination, and a smaller preoperative relative CSA of the paraspinal muscle on MRI.

The Fate of Adjacent Segments After Anterior Cervical Discectomy and Fusion: The Influence of an Anterior Plate System.

OBJECTIVE: The purpose of this study was to compare anterior cervical discectomy and fusion with cage alone (ACDF-CA) and anterior cervical discectomy and fusion with cage and plate (ACDF-CP) with regard to adjacent segment degeneration (ASD) diagnosed by the use of CT and MRI with retrospective matched cohort design. METHODS: This study enrolled 68 patients who underwent single-level ACDF who were diagnosed with cervical degenerative disc disease and were followed up for at least 2 years with plain radiographs, computed tomography, and magnetic resonance imaging. The patients were divided into 2 groups according to the operation method: ACDF-CA (33 patients) and ACDF-CP (35 patients). RESULTS: ASD occurred in 4 of 33 patients who underwent ACDF-CA and 9 of 35 patients who underwent ACDF-CP as determined by computed tomography and magnetic resonance imaging. The upper segment range of motion and lower segment range of motion increased in both groups postoperatively. The increase was greater in the ACDF-CP group without statistical significance. The upper segment disc height and lower segment disc height gradually decreased in both groups over time. The decrease was significantly greater in the ACDF-CP group at each follow-up visit. Pseudarthrosis and cage subsidence was observed more in the ACDF-CA group. The pain intensity for the neck in the ACDF-CA group was increased 12 and 24 months postoperatively. CONCLUSIONS: The anterior plate system in ACDF tends to increase adjacent segmental motion and decrease adjacent segmental disc height. In addition, irrespective of clinical symptoms, ACDF-CP has a greater tendency to result in ASD than ACDF-CA after 24 months after surgery.

Comparison of Outcomes of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Microdiscectomy for Young Adults: A Retrospective Matched Cohort Study.

OBJECTIVE: There have been only a few studies on surgical treatment of lumbar disc herniation (LDH) in young adults. In addition, previous studies do not provide detailed information on the surgical outcomes for young adults with LDH. The purpose of this study was to compare the outcome of transforaminal percutaneous endoscopic lumbar discectomy (PELD) and open lumbar microdiscectomy for active, young adults (age 20-25 years). METHODS: We performed retrospective chart and radiography. The patients were divided into 2 groups according to the surgical methods. Group A included the patients who underwent transforaminal PELD, and Group B included the patients who underwent open lumbar microdiscectomy for LDH at L4/5. After we matched for several factors, 32 young patients in group A and 34 young patients in group B were analyzed. We compared the outcomes between the 2 groups in terms of clinical, radiologic, perioperative outcomes, and surgery-related complications. RESULTS: The clinical results for leg pain and radiologic results for decompression were the same in both groups. Most of complications in the PELD group occurred in the early phase. The recurrence rate and operation failure rate was no difference between the groups. The PELD brought significant advantages in the following areas: back pain, operation time, blood loss, hospital stay, and return-to-work. CONCLUSIONS: Although a learning curve is needed in order to become familiar with PELD, PELD seemed to be a good choice for disc herniation in the lumbar spine for active, young adults.

Learning Curve of Percutaneous Endoscopic Lumbar Discectomy Based on the Period (Early vs. Late) and Technique (in-and-out vs. in-and-out-and-in): A Retrospective Comparative Study.

OBJECTIVE: To report the learning curve of percutaneous endoscopic lumbar discectomy (PELD) for a surgeon who had not been previously exposed to this procedure based on the period and detailed technique with a retrospective matched comparative design. METHODS: Of 213 patients with lumbar disc herniation encountered during the reference period, 35 patients who were followed up for 1 year after PELD were enrolled in this study. The patients were categorized by the period and technique of operation : group A, the first 15 cases, who underwent by the 'in-and-out' technique; group B, the next 20 cases, who underwent by the 'in-and-out-and-in' technique. The operation time, failure rate, blood loss, complication rate, re-herniation rate, the Visual Analogue Scale (VAS) for back and leg were checked. The alteration of dural sac cross-sectional area (DSCSA) between the preoperative and the postoperative MRI was checked. RESULTS: Operative time was rapidly reduced in the early phase, and then tapered to a steady state for the 35 cases receiving the PELD. After surgery, VAS scores for the back and leg were decreased significantly in both groups. Complications occurred in 2 patients in group A and 2 patients in group B. Between the two groups, there were significant differences in operative time, improvement of leg VAS, and expansion of DSCSA. CONCLUSION: PELD learning curve seems to be acceptable with sufficient preparation. However, because of their high tendency to delayed operation time, operation failure, and re-herniation, caution should be exercised at the early phase of the procedure.

Clinical experience and management of cervico-thoracic epidural hematoma.

Spinal epidural hematoma (SEH) causing acute myelopathy is rare. The usual clinical presentation of a SEH is sudden severe neck or back pain that progresses toward paraparesis or quadriparesis, depending on the level of the lesion. Recent studies have shown that early decompressive surgery is very important for patient's recovery. We experienced five patients of cervico-thoracic epidural hematomas associated with neurologic deficits that were treated successfully with surgical intervention.