A Longer Duration of Myelopathy Symptoms is Associated With the Lack of Intraoperative Motor Evoked Potential Improvement During Decompressive Cervical Myelopathy Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: We aim to investigate the relationship between the intraoperative motor evoked potential (MEP) signal changes during surgical treatment of cervical myelopathy with postoperative functional outcomes and determine what factors correlate with MEP signal changes. SUMMARY OF BACKGROUND DATA: Intraoperative neurophysiologic monitoring with MEP for cervical cord decompression can potentially predict postoperative neurological complications. MATERIALS AND METHODS: We prospectively collected data from 114 consecutive cervical compressive myelopathy patients who underwent decompressive cervical spine surgery. Functional outcomes were measured preoperatively and postoperatively at the 6-month mark, using the modified Japanese Orthopedic Association score. RESULTS: Among the 114 patients, 87 patients showed significant MEP improvement, 1 patient with MEP degeneration, 3 patients with no change in MEP, and 23 patients with MEP change, but which eventually returned to baseline. Univariate analysis showed that patients with MEP improvement had similar 6-month functional and Japanese Orthopedic Association scores compared with patients who did not have MEP improvement. Critically, a longer duration of symptoms was shown to have a statistically significant relationship with patients who did not have MEP improvement on univariate analysis (49.2 wk in patients with no MEP improvement compared with 34.59 wk in patients with MEP improvement, P = 0.03) but this did not translate to differences in functional outcomes. There was also no statistically significant association between the functional outcome scores and demographics, surgical, or radiologic factors. CONCLUSIONS: Our study shows that the duration of symptoms is not attributed to lower functional outcomes but is associated with a lack of MEP improvement. LEVEL OF EVIDENCE: Level III.

The Effect of Body Mass Index on Long-Term Patient-Reported Outcome Scores after Anterior Cervical Discectomy and Fusion in an Asian Population: A 2-Year Study.

STUDY DESIGN: Retrospective cohort study. PURPOSE: This study aims to analyze the relationship between body mass index (BMI) subjective patient-reported outcomes (PRO) after 1- and 2-level anterior cervical discectomy and fusion (ACDF). OVERVIEW OF LITERATURE: The prevalence of cervical spondylosis and ACDF in expected to continue rising among the aging population of Asia. Moreover, the prevalence of obesity is also increasing. However, limited information is available about the mechanism by which BMI affects PRO after ACDF. METHODS: Total 878 patients underwent ACDF between 2000 and 2015. After excluding patients with previous cervical instrumentation, >2 levels fused, missing BMI measurement, or neoplastic/trauma indication for surgery, 535 patients were included. The PRO measures of the Neck Disability Index, Numerical Pain Rating Scale (NPRS) for Neck Pain, NPRS for Limb Pain, American Academy of Orthopaedic Surgeons-Neurogenic Symptom Score, and Japanese Orthopaedic Association myelopathy score were used. Patients were grouped based on their preoperative BMI, as per the World Health Organization guidelines for Asian populations. PRO scores were collected preoperatively, at 6 months postoperatively, and 2 years postoperatively. A generalized linear model was used to analyze the relationship of BMI category with the individual score, accounting for several factors that are likely to affect the outcomes. RESULTS: Total 19 (3.4%) were underweight, 155 (28.0%) were normal weight, 112 (20.3%) were overweight, and 267 (48.3%) were obese. Patients across all BMI categories experienced significant and similar improvements in their postoperative PRO scores. There were no significant differences in the preoperative, 6-month postoperative, and 2-year postoperative PRO scores of the groups. Rate of reoperation was highest in patients with grade II obesity at 8.07%; however, the difference was not statistically significant. CONCLUSIONS: Irrespective of the BMI, all patients exhibited similar satisfactory outcomes following ACDF. The results support surgery in all subgroups of patients with symptomatic nerve compression in the cervical spine.

Elderly Patients Undergoing Minimally Invasive Transforaminal Lumbar Interbody Fusion May Have Similar Clinical Outcomes, Perioperative Complications, and Fusion Rates As Their Younger Counterparts.

BACKGROUND: Although several studies have suggested that minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) may be especially beneficial in the elderly population due to lower operative morbidity and faster postoperative recovery, there are limited studies investigating the functional outcomes, quality of life, and satisfaction in elderly patients after MIS-TLIF. Furthermore, existing studies had substantial clinical, diagnostic, and surgical heterogeneity. QUESTIONS/PURPOSES: We asked if elderly patients could experience comparable (1) patient-reported pain, disability and quality of life, (2) perioperative complications, and (3) radiological fusion rates as their younger counterparts after MIS-TLIF. METHODS: Prospectively collected registry data of patients undergoing primary, single-level, MIS-TLIF for degenerative spondylolisthesis between 2012 and 2014 were reviewed. We included 168 patients, 39 of whom were at least 70 years old. Of the 129 patients younger than 70 years old, propensity-score matching was used to select 39 younger controls with adjustment for sex, BMI, American Society of Anesthesiologists score, and baseline clinical outcomes. Perioperative complications and radiologic data were compared. RESULTS: There was no difference in back pain (mean difference -0.3 [95% confidence interval -1.0 to 0.5]; p = 0.52); leg pain (mean difference -0.1 [95% CI to 0.6-0.5]; p = 0.85); Oswestry Disability Index (mean difference -2.9 [95% CI -8.0 to 2.2]; p = 0.26); and SF-36 physical (mean difference 3.0 [95% CI -0.7 to 6.8]; p = 0.107); and mental component summary (mean difference 1.9 [95% CI -4.5 to 8.2]; p = 0.56); up to 2 years postoperatively; 85% of younger patients and 85% of elderly patients were satisfied (p > 0.99) while 87% and 80%, respectively, had fulfilled expectations (p = 0.36). Four perioperative adverse events occurred in each group. There was also no difference in the rate of fusion (87% in younger patients and 90% in elderly patients; p = 0.135). CONCLUSIONS: When clinical and surgical heterogeneity were minimized, elderly patients undergoing minimally invasive transforaminal lumbar interbody fusion not only had comparable rates of perioperative complications but also experienced similar improvements in pain, function, and quality of life. A high rate of satisfaction was achieved. LEVEL OF EVIDENCE: Level II, prognostic study.

The Diagnostic Value of Magnetic Resonance Imaging in Identifying Unsuspected Malignancy in Patients Undergoing Percutaneous Vertebral Augmentation for Vertebral Compression Fractures.

BACKGROUND: The aim of this study was to identify the rate of unsuspected malignancy in vertebral compression fractures (VCFs) treated with percutaneous vertebral augmentation procedures (PVAPs). METHODS: From 2004-2015, 410 patients with VCFs underwent PVAPs with biopsy in a single tertiary hospital. All patients had preoperative magnetic resonance imaging (MRI) read by consultant radiologists and reviewed by the performing surgeon prior to PVAPs. All procedures were performed by fellowship-trained spine surgeons. A patient was considered to have an unsuspected malignancy if preoperative MRI was negative for malignancy but histology from the operative biopsy was positive. RESULTS: A total of 44 of 45 patients (97.8%) were identified to have malignancy on preoperative MRI. One patient had a negative MRI but positive biopsy (myeloma). This patient also had a positive myeloma panel. A total of 41 of 44 patients with suspicious MRI preoperatively had a history of malignancy with histology consistent with metastatic spread from the known primary. Two patients had a new diagnosis of malignancy (1 breast carcinoma, 1 metastatic cancer likely of breast or gastrointestinal origin). Younger patients were more likely to have a VCF due to malignancy (odds ratio, 28.33 in age < 60 years). CONCLUSIONS: Almost 98% of patients with malignancy (44 of 45 patients) could be successfully identified with a preoperative MRI. The addition of a myeloma panel to MRI identified all patients with malignancies prior to PVAP in our study. We recommend MRI and myeloma panel for all patients with VCFs to be treated with PVAPs. For patients who undergo a PVAP, routine biopsy should be performed.

Posterior interosseous artery flap: our experience and review of modifications done.

This is a report on the 14 PIA flaps done in our centre for traumatic hand defects over both volar and dorsal aspects, as well as thumb reconstruction over a six-year period from 2000 to 2007. We were able to achieve reach to the DIPJ with the use of fascia extension and better flap survival with more perforators captured in the flap.