Longitudinal Spinous-Splitting Laminoplasty with Coral Bone for the Treatment of Cervical Adjacent Segment Degenerative Disease: A 5-Year Follow-up Study.

This study was designed to analyze the causes of cervical adjacent segment degenerative disease (ASDis), evaluate the surgical outcomes of longitudinal spinous-splitting laminoplasty with coral bone (SLAC) during cervical reoperation, and accumulate data on reoperation with SLAC in a primary hospital. Based on the inclusion and exclusion criteria, we conducted a retrospective study involving 52 patients who underwent cervical reoperation for ASDis using SLAC at the spinal surgery department of the Beijing Jishuitan Hospital from 1998 to 2014. Among them, 39 were treated with anterior cervical fusion and internal fixation during the first operation (anterior cervical corpectomy with fusion [ACCF], n = 24; anterior cervical discectomy and fusion [ACDF], n = 11; and cervical disc arthroplasty [CDA], n = 4). Outcomes were the Japanese Orthopaedic Association (JOA) score, neck disability index (NDI) score, upper limb/neck and shoulder evaluated using a visual analogue scale (VAS), and rates of ASDis. In patients who underwent an anterior cervical approach in the first instance, the incidence of ASDis was significantly higher in the C3/4 gap than in the other gaps. In the ACCF group, the lateral radiograph of the cervical spine revealed that the distance between the anterior cervical plate and the adjacent segment disc was <5 mm in 15 (62.5%) cases and five (12.8%) cases, respectively, the internal fixation screws broke into the annulus of the adjacent segment. After the first SLAC, ASDis developed at C2/3 and C3/4 in four (30.8%) and eight (61.5%) cases, respectively. After reoperation, all cases were followed up for >5 (average, 6.2) years. The pre-reoperation and last follow-up values were as follows: mean Japanese Orthopaedic Association score, 10.2 ± 1.5 vs 15.5 ± 0.7 (P = 0.03); neck disability index, 26.2 vs 13.6 points (P = 0.01); upper-limb visual analog scale (VAS) score, 6.1 vs 2.6 points (P = 0.04); and neck and shoulder VAS score, 6.6 vs 2.1 points (P = 0.03). SLAC is a simple technique in which the local anatomy is clearly visible and satisfactory clinical outcomes are obtained.

Comparison of Outcomes between Robot-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion and Oblique Lumbar Interbody Fusion in Single-Level Lumbar Spondylolisthesis.

OBJECTIVE: To compare the safety and effectiveness of robot-assisted minimally invasive transforaminal lumbar interbody fusion (Mis-TLIF) and oblique lumbar interbody fusion (OLIF) for the treatment of single-level lumbar degenerative spondylolisthesis (LDS). METHODS: This is a retrospective study. Between April 2018 and April 2020, a total of 61 patients with single-level lumbar degenerative spondylolisthesis and treated with robot-assisted OLIF (28 cases, 16 females, 12 males, mean age 50.4 years) or robot-assisted Mis-TLIF (33 cases, 18 females, 15 males, mean age 53.6 years) were enrolled and evaluated. All the pedicle screws were implanted percutaneously assisted by the TiRobot system. Surgical data included the operation time, blood loss, and length of postoperative hospital stay. The clinical and functional outcomes included Oswestry Disability Index (ODI), Visual Analog scores (VAS) for back and leg pain, complication, and patient's satisfaction. Radiographic outcomes include pedicle screw accuracy, fusion status, and disc height. These data were collected before surgery, at 1 week, 3 months, 6 months, and 12 months postoperatively. RESULTS: There were no significantly different results in preoperative measurement between the two groups. There was significantly less blood loss (142.4 ± 89.4 vs 291.5 ± 72.3 mL, P < 0.01), shorter hospital stays (3.2 ± 1.8 vs 4.2 ± 2.5 days, P < 0.01), and longer operative time (164.9 ± 56.0 vs 121.5 ± 48.2 min, P < 0.01) in OLIF group compared with Mis-TLIF group. The postoperative VAS scores and ODI scores in both groups were significantly improved compared with preoperative data (P < 0.05). VAS scores for back pain were significantly lower in OLIF group than Mis-TLIF group at 1 week (2.8 ± 1.2 vs 3.5 ± 1.6, P < 0.05) and 3 months postoperatively (1.6 ± 1.0 vs 2.1 ± 1.1, P < 0.05), but there was no significant difference at further follow-ups. ODI score was also significantly lower in OLIF group than Mis-TLIF group at 3 months postoperatively (22.3 ± 10.0 vs 26.1 ± 12.8, P < 0.05). There was no significant difference in the proportion of clinically acceptable screws between the two groups (97.3% vs 96.2%, P = 0.90). At 1 year, the OLIF group had a higher interbody fusion rate compared with Mis-TLIF group (96.0% vs 87%, P < 0.01). Disc height was significantly higher in the OLIF group than Mis-TLIF group (12.4 ± 3.2 vs 11.2 ± 1.3 mm, P < 0.01). Satisfaction rates at 1 year exceeded 90% in both groups and there was no significant difference (92.6% for OLIF vs 91.2% for Mis-TLIF, P = 0.263). CONCLUSION: Robot-assisted OLIF and Mis-TLIF both have similar good clinical outcomes, but OLIF has the additional benefits of less blood loss, less postoperative hospital stays, higher disc height, and higher fusion rates. Robots are an effective tool for minimally invasive spine surgery.

Occipital-C2 transarticular fixation for occipitocervical instability associated with occipitalization of the atlas in patients with klippel-feil syndrome, using intraoperative 3-dimensional navigation system.

STUDY DESIGN: Retrospective case series. OBJECTIVE: The aim of this study was to describe the clinical outcomes of cervical reduction and occipital-C2 transarticular (OCTA) fixation with an assistance of intraoperative 3-dimensional navigation system (ITNS) during the treatment of reducible occipitocervical instability (OCI) in patients with Klippel-Feil syndrome (KFS) with occipitalization of the atlas and fusion of C2-C3. SUMMARY OF BACKGROUND DATA: Patients with KFS have congenital fusions of at least 2 cervical segments and may gradually develop symptoms at the hypermobile articulations adjacent to the cervical synostosis. This is particularly common in patients with KFS with occipitalization of the atlas and C2-C3 fusion. These patients may be at risk for instability and neurological complications of the occipitocervical junction that require occipitocervical reconstruction and fusion. Numerous treatment techniques are available for this pathological condition. However, there has yet to be a study of reducible OCI, showing successful treatment with intraoperative reduction and posterior OCTA fixation using ITNS. METHODS: From 2006 to 2011, 9 patients with KFS with reducible OCI attributed to occipitalization of the atlas and C2-C3 fusion were surgically treated. After a limited foramen magnum decompression, reduction of the OCI was conducted by intraoperative cervical traction and extension, followed by OCTA fixation using a direct posterior approach and with the assistance of ITNS. The follow-up period ranged from 6 to 60 months (mean, 31 mo). RESULTS: Good decompression and bone fusion were achieved in all the patients. The clinical symptoms had improved for all patients. There were no intraoperative or postoperative complications. CONCLUSION: In patients with KFS with occipitalization of the atlas and C2-C3 fusion, manual cervical traction in tandem with cervical extension, followed by posterior OCTA fixation and fusion provides a safe, effective treatment of OCI and ventral brainstem impingement. IFTN is a feasible tool for monitoring cervical reduction and OCTA screw insertion in patients with KFS with this pathological condition.

[One-stage posterior approach spinal reconstruction for severe lumbar burst fracture].

OBJECTIVE: To evaluate the clinical therapeutic outcomes for severe burst fracture of lumbar vertebrae via a posterior approach for one-stage spinal "three-column" reconstruction. METHODS: An retrospective analysis of data was performed for 21 patients with severe burst fracture of lumbar vertebrae undergoing a posterior approach for one-stage spinal "three-column" reconstruction from 2005 to 2010. It was compared with previous 15 cases undergoing a staged anteroposterior approach. The operative duration, volume of blood loss, pre- and post-operative imaging measurements of kyphosis and vertebral height and nerve function recovery were evaluated. RESULTS: The values of operative duration and volume of blood loss in the one-stage posterior approach group were significantly less than those of the two-stage anteroposterior approach group [(263 ± 72) min vs (439 ± 75) min, t = -5.303, P < 0.01; (1143 ± 296) ml vs (1471 ± 399) ml, t = -2.169, P = 0.042)]. Statistical significance existed in postoperative kyphosis between two groups [(0.5 ± 2.0)° vs (3.9 ± 2.6)°, t = -3.336, P = 0.003]. Vertebral height had no statistical significance pre- and post-operatively between two groups while restoration of vertebral height did [(0.47 ± 0.19) mm vs (0.26 ± 0.15) mm, t = 2.669, P = 0.015]. CONCLUSION: Posterior approach for one-stage vertebral resection, mesh implantation, pedicle screws and rod internal fixation for reconstructing spinal "three-column" structures offers excellent feasibility and safety. And it may avoid complications associated with an anteroposterior approach for two-stage procedures. The median length of hospital stay is also reduced.

Clinical and radiographic results of cervical artificial disc arthroplasty: over three years follow-up cohort study.

BACKGROUND: Theoretic advantages of cervical disc arthroplasty include preservation of normal motion and biomechanics in the cervical spine, and reduction of adjacent-segment degeneration. The clinical and radiographic effects of cervical disc arthroplasty in short term have been ascertained. The aim of this study is to research the data of mid-term results. METHODS: In this prospective cohort study, 50 patients who underwent cervical disc arthroplasty from December 2003 to January 2006 were enrolled. There were 39 patients who received 1-level disc arthroplasty, and 11 patients received 2-level disc arthroplasty, with an average age of 50.9 years (range from 29 to 73). The median follow-up was 41.85 months (range from 36.00 - 55.63 months). Patients were followed prospectively with respect to their symptoms, neurologic signs, and radiographic results. RESULTS: The median value of Japanese Orthopaedic Association (JOA) score was 14.0 before surgery, and 16.5 at the most recent follow-up (P < 0.01). The median value of the recovery rate of the JOA score was 92.2%. The preoperative range of motion (ROM) at the indexed level was (10.40 ± 4.97)°, which has significantly correlated with the most recent follow-up ROM which was (8.56 ± 4.76)° (P < 0.05, r = 0.33). The ROM at the operative level at the most recent follow-up was greater than the value at the 3-month follow-up of (7.52 ± 3.37)° (P < 0.05). The preoperative functional spinal unit (FSU) angulation was (-0.96 ± 6.52)°, which was not significantly correlated with that of the most recent follow-up value of (-2.65 ± 7.95)° (P < 0.01, r = 0.53). The preoperative endplate angulation was (2.61 ± 4.85)°, which had no significant correlation with that of the most recent follow-up value of (0.71 ± 6.41)° (P > 0.05). CONCLUSIONS: The clinical and radiographic results of cervical disc arthroplasty are good in mid-term follow-up. The normal range of motion of the operated level and the biomechanics in the cervical spine are well preserved.

[Adjacent segment mobility after anterior cervical discectomy and fusion].

OBJECTIVE: To investigate the mobility changes of adjacent segments after fusion retrospectively. METHODS: A total of 28 patients underwent standard anterior cervical arthrodesis. The kinematic changes occurred at segments adjacent to cervical arthrodesis through a coral bone graft and plating system. The mean follow-up period was 6.3 ± 1.6 years (3.6 - 10.5). Lateral radiographic views of cervical spine in flexion and extension were obtained at pre-operation and follow-up. Rotational motion at adjacent levels was quantified. RESULTS: Sagittal range of motion (ROM) at adjacent cranial level was 11.2° ± 5.0° at pre-operation and 11.4° ± 6.4° at follow-up. It was not statistically significant (P > 0.01). At adjacent caudal level, ROM was 9.8° ± 5.3°, but 10.2° ± 4.6° at follow-up. But it was not statistically significant (P > 0.01). During the follow-up, entire cervical motion (C2-C7) decreased significantly from 46.8° ± 13.4° to 36.8° ± 9.6° in single-level fusion group, but from 48.6° ± 14.6° to 39.9° ± 7.2° in double-level fusion group. CONCLUSION: The assumption of an iatrogenically elevated adjacent level mobility by cervical fusion is refuted by the present study.

[Short-term clinical outcome of modified expansive open-door cervical laminoplasty preserving posterior extensor musculature inserted into C2 and C7 spinous process].

OBJECTIVE: To assess the effect of modified cervical expansive open-door laminoplasty preserving the posterior extensor musculature inserted into the C2 and C7 spinous process upon maintaining the cervical lordotic alignment and axial syndrome and to determine whether preserving the posterior extensor musculature inserted into C2 and C7 spinous process can reduce the complications. METHODS: Twenty-eight patients undergoing modified cervical expansive open-door laminoplasty preserving the posterior extensor musculature inserted into the C2 and C7 spinous process and 21 patients undergoing conventional C3-C7 cervical expansive open-door laminoplasty were investigated in pre-operative, post-operative and 3-month follow-up. The investigators assessed the effects of two different cervical laminoplasty types in the recovery rate of JOA score, the changes of Cobb angle and Ishihara's index, axial syndrome, operating duration and intra-operative blood loss, analyzed the results in SPSS and tried to find the difference in two operative types. RESULTS: There were the same results in the recovery rate of JOA score and intra-operative blood loss in modified expansive open-door cervical laminoplasty group and the conventional C3-C7 cervical expansive open-door laminoplasty group. The smaller changes of Cobb angle and Ishihara's index in the follow-up of modified laminoplasty group were found. The modified laminoplasty group had fewer patients suffering the axial syndrome in follow-up. The operating duration was shorter in the modified laminoplasty group. CONCLUSION: Preventing muscle injuries in cervical laminoplasty can reduce the incidence of complications. The modified expansive open-door cervical laminoplasty preserving the posterior extensor musculature inserted into C2 and C7 spinous process can protect cervical posterior extensor musculature. This is helpful to maintain the cervical lordotic alignment and reduce the incidence of post-operative axial syndrome.

[Transforaminal lumbar interbody fusion by minimally invasive approach in the treatment of simple foraminal stenosis].

OBJECTIVE: To study the short-term clinical outcome of transforaminal lumbar interbody fusion (TLIF) by minimally invasive approach in the treatment of simple foraminal stenosis (SFS). METHODS: Thirty four cases (M: F = 19: 15) diagnosed with SFS from January. 2007 to March. 2009 were included. Age ranged from 47 to 62 (mean: 57) years old. Patients generally had degenerative changes and decreased disc height on X-ray films at the indexed level. No stenosis within the spinal canal was found on myelograph and CTM. Sagittal images of MRI usually demonstrated narrowed foramina. Selective radiculograph and radicular blocking was used to make the definite diagnosis and to locate the involved nerve root. Double paramedian intermuscular approaches were adopted in all cases. Minimally invasive retractor systems, such as X-Tube and Pipeline etc., were used to facilitate the exposure, pedicle screw instrumentation and TLIF. RESULTS: The average operation time was 2.76 hours. The average blood loss was 387.16 ml. All patients were encouraged to ambulate 2-3 days post-operation. The incisions healed uneventfully. At the final follow-up, instrumentations were maintained in an excellent position in all cases and JOA score improved by 31.14%. CONCLUSIONS: TLIF by minimally invasive approach is an effective method in treating patients with lumbar foraminal stenosis. The short-term clinical outcomes are satisfactory. This approach may avoid the injuries to paraspinal muscles, posterior ligaments, dura and nerve root of the uninvolved side.

[Comparison between CT-discography and magnetic resonance imaging in lumbar disc diseases].

OBJECTIVE: To investigate the clinical importance of discography and CT after discography (CTD) in the lumbar disc diseases, and make a comparison between CTD and magnetic resonance imaging (MRI). METHODS: 265 patients with back and leg pain 177 males and 79 females, age 39 +/- 16, underwent discography and CT 2 hours later on 298 discs. All the patients' discs were classified into 7 types according to the findings by discography and CTD. Comprehensive MRI pictures were available in 237 of the 265 patients (with 257 discs); they accepted the MRI classification and were compared with the CT-discographic findings. RESULTS: 245 patients underwent operation, among which 247 discs showed visual lesions during the procedure and 238 cases (96.4%) had their disc diseases diagnosed accurately through discography and CTD. Considering the positive screening rate for the discogenic abnormality, the difference was of statistical significance between the CTD and MRI groups (P < 0.01). MRI was considered to have limited value in the disc diseases with passive discographic finding. CONCLUSION: Discography is an efficient, sound and safe assistant diagnostic tool, which can get some special information about disc. The matched-group study shows that the MRI and CTD can not be re placed by each other. MRI may act as the screening tool for disc diseases, but is inferior to CTD, especially for the contiguous disc structure in the spinal fixation procedure.

[Accuracy of CT-based navigation of pedicle screws implantation in the cervical spine compared with X-ray fluoroscopy technique].

OBJECTIVE: To evaluate the feasibility and accuracy of cervical spine pedicle screw fixation assisted by X-ray fluoroscopy and CT-based navigation system. METHODS: 145 cervical pedicle screws were placed assisted by X-ray fluoroscopy and 159 cervical pedicle screws were placed assisted by CT-based navigation system. Screw positions were evaluated by postoperative CT scans or C-arm X-ray 3 dimensional reconstruction. RESULTS: In the computer- assisted group, 155 (97.5%) screws were found completely within their pedicles compared with 133 (91.7%) correctly placed screws in the X-ray assisted group (P < 0.05). The process of navigation investigated in twenty patients showed that the mean time for registration and surface matching was 3.5 (range from 2 to 8 minutes) minutes and the mean time for screw-marker insertion was 2 (range from 1 to 3.5 minutes) minutes with the mean position deviation 0.31 mm (0.12-0.56 mm) per screw. Only twice C-arm fluoroscopy were performed to verify the accuracy of one screw position intraoperatively. No severe complications like neurovascular lesion occurred in both groups. CONCLUSION: CT-based navigation system can increase the accuracy of cervical pedicle screw implantation significantly.

[Cervical posterior laminoplasty operation using T-saw and coralline hydroxyapatite spacer].

OBJECTIVE: To assess the efficacy of using T-saw and coralline hydroxyapatite (CHA) spacer in the cervical spinous process-splitting laminoplasty. METHODS: 38 patients were operated with cervical laminoplasty using T-saw and CHA spacer, among them there were 31 multisegmental cervical spondylotic myelopathy patients, 5 ossification of posterior longitudinal ligament (OPLL) patients, 2 anterior fusion failure patients. All the patients were evaluated by JOA scores. RESULTS: we followed the 38 patients for average 26 months. Numbness,strength and gait were improved obviously. The flat rate of spinal cord in MRI improved 0.23;CHA fusion percentage 74%; no primary spinal cord injury was found. Average operation time was 2 hour 50 min;average bleeding during the operation was 280 ml; The average JOA score improve rate was 61%. CONCLUSION: The methods, using T-saw and CHA spacer in the cervical spinous process-splitting laminoplasty, which was characterized by simple, short time on operation and thorough decompression of spinal cord, was a ideal optional method in the cervical laminoplasty operation.