The Establishment of a Novel Upper Cervical Complex Fracture Classification System.

BACKGROUND CONTEXT: Upper cervical complex fractures are associated with high rates of neurological damage and mortality. The Dickman's classification is widely used in the diagnosis of upper cervical complex fractures. However, it falls short of covering the full spectrum of complex fractures. This limitation hinders effective diagnosis and treatment of these injuries. PURPOSE: To address the diagnostic gap in upper cervical complex fractures, the study introduces a novel classification system for these injuries, assessing its reliability and usability. STUDY DESIGN: Proposal of a new classification system for upper cervical complex fractures. PATIENT SAMPLE: The study comprised the clinical data of 242 patients with upper cervical complex fractures, including 32 patients treated at our hospital, along with an additional 210 cases from the literature. OUTCOME MEASURES: The inter-observer and intra-observer reliability (kappa coefficient, κ) of this classification system were investigated by 3 spine surgeons. The three researchers independently re-evaluated the upper cervical complex fracture classification system 3 months later. METHODS: The proposed classification categorizes upper cervical complex fractures into three main types: Type I combines odontoid and Hangman's fractures into two subtypes; Type II merges C1 with odontoid/Hangman's fractures into three subtypes; and Type III encompasses a combination of C1, odontoid, and Hangman's fractures, divided into two subtypes. Meanwhile, a questionnaire was administered in 15 assessors to evaluate the system's ease of use and clinical applicability. RESULTS: A total of 45 cases (18.6%) unclassifiable by Dickman's classification were successfully categorized using our system. The mean κ value of inter-observer reliability was 0.783, indicating substantial reliability. The mean κ value of intra-observer reliability was 0.862, indicating almost perfect reliability. Meanwhile, thirteen assessors (87.7%) stated that the classification system is easy to remember, easy to apply, and they expressed intentions to apply it in clinical practice in the future. CONCLUSIONS: This system not only offers high confidence and reproducibility but also serves as a precise guide for clinicians in formulating treatment plans. Future prospective applications are warranted to further evaluate this classification system.

Comparative Study of Preoperative Sagittal Spinal Pelvic Alignment in Patients with Cervical Spondylotic Radiculopathy, Ossification of the Posterior Longitudinal Ligament, and Cervical Spondylotic Myelopathy.

OBJECTIVES: Cervical spondylosis may lead to changes in the sagittal parameters of the neck and trigger compensatory alterations in systemic sagittal parameters. However, there is currently a dearth of comparative research on the changes and compensatory alterations to sagittal parameters resulting from different types of cervical spondylosis. This study compared the preoperative sagittal alignment sequences among patients with cervical spondylotic radiculopathy (CSR), ossification of the posterior longitudinal ligament (OPLL), and cervical spondylotic myelopathy (CSM) caused by factors resulting from non-OPLL factors. MATERIALS AND METHODS: Full length lateral X-ray of the spine and cervical computed tomography (CT) of 256 patients (134 men, 122 women; mean age, 56.9 ± 9.5 years) were analyzed retrospectively. A total of 4096 radiomics features were measured through the lateral X-ray by two spinal surgeons with extensive experience. The clinical symptoms measures were the Japanese Orthopaedic Association (JOA) score, number of hand actions in 10 s, hand-grip strength, visual analog scale (VAS) score. Normally distributed data was compared using one-way analysis of variance (ANOVA) for parametric variables and χ2 test were used to analyze the categorical data. RESULTS: In the OPLL group, the C2-C7 Cobb angle was greater than in the CSR and CSM groups (19.8 ± 10.4°, 13.3 ± 10.3°, and 13.9 ± 9.9°, respectively, p < 0.001). Additionally, the C7-S1 SVA measure was found to be situated in the anterior portion with regards to the CSM and CSR groups (19.7 ± 58.4°, -6.3 ± 34.3° and -26.3 ± 32.9°, p < 0.001). Moreover, the number of individuals with C7-S1 SVA >50 mm was significantly larger than the CSM group (26/69, 11/83, p < 0.001). In the CSR group, the TPA demonstrated smaller values compared to the OPLL group (8.8 ± 8.5°, 12.7 ± 10.2°, p < 0.001). Furthermore, the SSA was comparatively smaller as opposed to both the OPLL and CSM groups (49.6 ± 11.2°, 54.2 ± 10.8° and 54.3 ± 9.3°, p < 0.05). CONCLUSION: Patients with OPLL exhibit greater cervical lordosis than those with CSR and CSM. However, OPLL is more likely to result in spinal imbalance when compared to the CSM group. Furthermore, OPLL and CSM patients exhibit anterior trunk inclination and worse global spine sagittal parameters in comparison to CSR patients.

Biomechanical Effects of Multi-segment Fixation on Lumbar Spine and Sacroiliac Joints: A Finite Element Analysis.

OBJECTIVE: Spine fixation surgery affects the biomechanical environment in the sacroiliac joint (SIJ), which may lead to the SIJ pain or degeneration after surgery. The purpose of this study is to determine the impact of the number and position of fixed segments on the SIJs and provide references for surgeons to plan fixation levels and enhance surgical outcomes. METHODS: The intact lumbar-pelvis finite element (FE) models and 11 fixation FE models with different number and position of fixed segments were developed based on CT images. A 400N follower load and 10° range of motion (ROM) of the spine were applied to the superior endplate of L1 to simulate the flexion, extension, bending and torsion motion after surgery. The peak stress on the SIJs, lumbar intervertebral discs, screws and rods were calculated to evaluate the biomechanical effects of fixation procedures. RESULTS: With the lowermost instrumented vertebra (LIV) of L5 or S1, the peak stress on SIJs increased with the number of fixed segments increasing. The flexion motion led to the greater von Mises stress on SIJ compared with other load conditions. Compared with the intact model, peak stress on all fixed intervertebral discs was reduced in the models with less than three fixed segments, and it increased in the models with more than three fixed segments. The stress on the SIJ was extremely high in the models with all segments from L1 to L5 fixed, including L1-L5, L1-S1 and L1-S2 fixation models. The stress on the segment adjacent to the fixed segments was significant higher compared to that in the intact model. The peak stress on rods and screws also increased with the number of fixed segments increasing in the flexion, extension and bending motion, and the bending and flexion motions led to the greater von Mises stress on SIJs. CONCLUSION: Short-term fixation (≤2 segments) did not increase the stress on the SIJs significantly, while long-term segment fixation (≥4 segments) led to greater stress on the SIJs especially when all the L1-L5 segments were fixed. Unfixed lumbar segments compensated the ROM loss of the fixed segments, and the preservation of lumbar spine mobility would reduce the risks of SIJ degeneration.

Can the 6-minute Walking Test Assess Ambulatory Function Impairment in Patients with Cervical Spondylotic Myelopathy?

STUDY DESIGN: Prospective cohort study. OBJECTIVE: Investigating the ability of a 6-minute walking test (6MWT) to assess functional status in patients with cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: The 6MWT provides an objective assessment of a patient's ability to walk. There is the potential for its application to the assessment of functional status in patients with CSM. MATERIALS AND METHODS: One hundred and thirty-five patients from our institution were prospectively enrolled from July 2022 to August 2023. A control group of age- and sex-matched healthy individuals was established. The 6MWT was conducted in strict accordance with established guidelines. The Nurick score, the Prolo score, the Cooper-myelopathy-scale score (CMS), the Japanese Orthopedic Association score (JOA) and the European-myelopathy-scale score (EMS) were assessed preoperatively. Visual Analog Scale (VAS) for pain or numbness and Oswestry Neck Disability Index (NDI) were also collected. Radiographic parameters were measured and recorded. Continuous variables between patients and controls were compared by applying the t-test. The chi-square test was used to compare gender ratios between groups. Pearson's correlation analysis was used to analyze the association between continuous variables and ordinal variables. Subgroups of CSM patients were analyzed according to global spinal alignment types, based on whether the SVA was greater than or equal to 50 mm. Clinical scores and imaging parameters were compared by t-test. RESULTS: The preoperative 6-minute walking distance (6MWD) of CSM patients was 309.34 ± 116.71 m, which was significantly lower than that of the controls (464.30 ± 52.59 m, P<.01). The 6MWD was significantly correlated with scores on all clinical scales except the VAS. CMS Lower extremity score had the strongest correlation with preoperative 6MWD in CSM patients (r=-.794 , P<.01). Of the sagittal alignment parameters, only C7 sagittal vertical axis (SVA) and T1 slope were significantly correlated with 6MWD(r=-.510,-0.360, respectively). CSM patients with SVA greater than 50 mm had significantly lower 6MWD than CSM patients with SVA less than or equal to 50 mm (168.00 ± 137.26 vs 346.24 ± 84.27 m, P<.01). CONCLUSIONS: The 6MWD of CSM patients was significantly lower than that of the healthy population and correlated well with commonly used clinical scales. The 6MWD can potentially assist in the assessment of functional status in patients with CSM.

Hysterectomy - a possible risk factor for operative intervention in female patients for degenerative lumbar spine conditions: a case control and cohort study.

BACKGROUND CONTEXT: Researchers have recently linked hysterectomy, which alters sex hormone levels, to diseases like osteoporosis, lumbar spondylolisthesis, hypertension and diabetes etc. However, the association between hysterectomy and lumbar disc herniation (LDH)/lumbar spinal stenosis (LSS) remains unclarified. PURPOSE: To determine whether there is a correlation between hysterectomy and surgical intervention for LDH/LSS in women, further substantiated through imaging and clinical research. STUDY DESIGN: A case control and cohort study. PATIENT SAMPLE: The study group comprised 1202 female patients aged 45 and older who had undergone operative treatment due to LDH/LSS (825 for LDH and 377 for LSS), and the comparison group comprised 1168 females without lumbar diseases who visited health examination clinic during the same period. One hundred and 2 hysterectomized patients were further selected (Hysterectomy cohort) and matched approximately with the control cohort at a 1:2 ratio from the study group with a minimum follow-up of 2 years. OUTCOME MEASURES: Odds Ratios (ORs) and 95% Confidence Intervals (CIs) were calculated to assess the association between hysterectomy and surgical intervention for LDH/LSS in women after adjusted by confounding factors. Patients from both the hysterectomy and control cohorts underwent a comprehensive assessment. This assessment included the evaluation of several parameters: the functional cross-sectional area, fat infiltration rate, relative functional cross-sectional area of the lumbar paravertebral muscles, facet joint degeneration grade, cartilage endplate damage, Modic changes for the L3/4-L5/S1 segments, Pfirrmann grade of lumbar disc degeneration, and disc height index for the L1/2-L5/S1 segments. Additionally, the Visual Analog Scale (VAS) and Japanese Orthopaedic Association (JOA) scores were recorded preoperatively and at the last follow-up. METHODS: Associations between hysterectomy and patients treated surgically for LDH or LSS were analyzed using multivariate binomial logistic regression analysis. Lumbar X-ray, computed tomography (CT) and magnetic resonance imaging (MRI) were used to evaluate the imaging variables. Imaging and clinical variables were compared. RESULTS: Hysterectomized women were associated with requiring surgery due to LDH/LSS, with ORs of 2.613 (p<.001) and 2.084 (p=.006), respectively. The imaging evaluation further revealed that the hysterectomy cohort had more severe degeneration of the paraspinal muscles, facet joints, endplates, and intervertebral discs, Modic changes at L3/4-L5/S1 segments, and intervertebral height reduction at L1/2-L5/S1 segments when compared to the control cohort (p<.01). Compared to the control cohort, the hysterectomy cohort exhibited higher preoperative and last follow-up VAS scores for low back pain, and last follow-up JOA scores (p<.01). CONCLUSIONS: Based on the findings of this study, it seems that women who have had a hysterectomy are correlated with requiring surgical intervention due to LDH/LSS. Imaging and clinical studies also indicate that hysterectomized patients exhibited more severe lumbar degeneration and back pain.

Classification of the Congenital Defect of the Lumbar Facet Joint: Case Report and Literature Review.

BACKGROUND: Congenital lumbar facet joint defect is a rare congenital developmental disorder with only a few reported cases in the literature, primarily affecting the L5-S1 segments. This study reports the first case of a defect in the left L3 inferior articular process; and presents a review of the existing literature on the subject, proposes a classification system, and validates the inter-observer and intra-observer reliability of this classification system. CASE PRESENTATION: A 14-year-old boy presented to our orthopedic clinic with persistent lower back pain for 1 month. Imaging analysis, including CT scans, 3D reconstruction, and MRI, revealed a congenital lumbar facet joint defect at the L3 level, which has not been reported. Conservative treatment resulted in a significant improvement in his symptoms, and he is currently under follow-up care. CONCLUSION: Congenital defect of the lumbar facet joint is a rare spinal condition. This article reports the first patient with a defect in the left L3 inferior articular process and conducts a comprehensive literature review, proposing a classification of articular process defects into five types. The two most common types are Types B and C. We have demonstrated that this system is reliable and reproducible and have described the treatment of each type.

Anti-Stress and Anti-ROS Effects of MnOx-Functionalized Thermosensitive Nanohydrogel Protect BMSCs for Intervertebral Disc Degeneration Repair.

Stem cell transplantation is proven to be a promising strategy for intervertebral disc degeneration (IDD) repair. However, replicative senescence of bone marrow-derived mesenchymal stem cells (BMSCs), shear damage during direct injection, mechanical stress, and the reactive oxygen species (ROS)-rich microenvironment in degenerative intervertebral discs (IVDs) cause significant cellular damage and limit the therapeutic efficacy. Here, an injectable manganese oxide (MnOx)-functionalized thermosensitive nanohydrogel is proposed for BMSC transplantation for IDD therapy. The MnOx-functionalized thermosensitive nanohydrogel not only successfully protects BMSCs from shear force and mechanical stress before and after injection, but also repairs the harsh high-ROS environment in degenerative IVDs, thus effectively increasing the viability of BMSCs and resident nucleus pulposus cells (NPCs). The MnOx-functionalized thermosensitive nanohydrogel provides mechanical protection for stem cells and helps to remove endogenous ROS, providing a promising stem cell delivery platform for the treatment of IDD.

Risk Factors for Surgical Treatment of Lumbar Degenerative Disc Disease in Middle-aged and Older Women: A Prospective Case-Control Study of 2370 Subjects.

OBJECTIVE: Given the distinct physiological and societal traits between women and men, we propose that there are distinct risk factors for lumbar degenerative disc disease surgeries, including lumbar disc herniation (LDH) and lumbar spinal stenosis (LSS), in middle-aged and older populations. However, few studies have focused on middle-aged and older women. This study aims to identify these risk factors specifically in this population. METHODS: In this case-control study, the study group comprised 1202 women aged ≥ 45 years who underwent operative treatment of lumbar degenerative disc disease (LDH, n = 825; LSS, n = 377), and the control group comprised 1168 women without lumbar disease who visited a health examination clinic during the same period. The study factors included demographics (age, body mass index [BMI], smoking, labor intensity, and genetic history), female-specific factors (menopausal status, number of deliveries, cesarean section, and simple hysterectomy), surgical history (number of abdominal surgeries, hip joint surgery, knee joint surgery, and thyroidectomy), and systemic diseases (hypercholesterolemia, hypertriglyceridemia, hyper-low-density lipoprotein cholesterolemia, hypertension, diabetes, cardiovascular disease, and cerebrovascular disease). Multivariate binary logistic regression analysis was used to calculate the odds ratio (OR) and 95% confidence interval (95% CI) of associated factors. RESULTS: The risk factors for surgical treatment of LDH in middle-aged and older women included BMI (OR = 1.603), labor intensity (OR = 1.189), genetic history (OR = 2.212), number of deliveries (OR = 1.736), simple hysterectomy (OR = 2.511), hypertriglyceridemia (OR = 1.932), and hyper-low-density lipoprotein cholesterolemia (OR = 2.662). For surgical treatment of LSS, the risk factors were age (OR = 1.889), BMI (OR = 1.671), genetic history (OR = 2.134), number of deliveries (OR = 2.962), simple hysterectomy (OR = 1.968), knee joint surgery (OR = 2.527), hypertriglyceridemia (OR = 1.476), hyper-low-density lipoprotein cholesterolemia (OR = 2.413), and diabetes (OR = 1.643). Cerebrovascular disease was a protective factor against surgery for LDH (OR = 0.267). CONCLUSIONS: BMI, genetic history, number of deliveries, simple hysterectomy, hypertriglyceridemia, and hyper-low-density lipoprotein cholesterolemia were independent risk factors for surgical treatment of both LDH and LSS in middle-aged and older women. Two disparities were found: labor intensity was a risk factor for LDH patients, and knee joint surgery and diabetes were risk factors for LSS patients.

Comparison of Clinical and Radiographic Outcomes Between Transforaminal Endoscopic Lumbar Discectomy and Microdiscectomy: A Follow-up Exceeding 5 Years.

OBJECTIVE: To compare the long-term clinical and radiographic outcomes of transforaminal endoscopic lumbar discectomy (TELD) versus microdiscectomy (MD). METHODS: The data of 154 patients with lumbar disc herniation (LDH) who underwent TELD (n = 89) or MD (n = 65) were retrospectively analyzed. The patients' clinical outcomes were evaluated using visual analogue scales for leg and low back pain, the Japanese Orthopaedic Association (JOA) score, and the Oswestry Disability Index (ODI). The evolution of radiographic manifestations was observed during follow-up. Potential risk factors for a poor clinical outcome were investigated. RESULTS: During a mean follow-up of 5.5 years (range, 5-7 years), the recurrence rate was 4.49% in the TELD group and 1.54% in the MD group. All scores significantly improved from preoperatively to postoperatively in both groups (p < 0.01). The improvement in the ODI and JOA scores was significantly greater in the TELD than MD group (p < 0.05). Forty-seven patients (52.8%) in the TELD group and 32 (49.2%) in the MD group had Modic changes before surgery, most of which showed no changes at the last follow-up. The degeneration grades of 292 discs (71.0%) were unchanged at the last follow-up, while 86 (20.9%) showed improvement, mostly at the upper adjacent segment. No significant difference was observed in the intervertebral height index or paraspinal muscle-disc ratio. CONCLUSION: Both TELD and MD provide generally satisfactory long-term clinical outcomes for patients with LDH. TELD can be used as a reliable alternative to MD with less surgical trauma. Modic type II changes, decreased preoperative intervertebral height, and a high body mass index are predictors of a poor prognosis.

Novel Modic grading scoring system and its clinical validation: a preliminary investigation.

PURPOSE: To propose a novel Modic grading scoring system and explore the relationship between the Modic grading score and disc degeneration, disc herniation, disc height, and clinical symptom scores. METHOD: In total, 194 patients were included in the study. The new Modic grading scoring system included four indicators: invaded vertebral height, invaded endplate length, endplate morphology, and grade of endplate defects. The severity of Modic changes was visually quantified by numerical scores, and the kappa value was used to verify the interobserver and intraobserver reliability. Spearman correlation analysis was used to explore the relationship between the Modic grading score and intervertebral disc degeneration, disc herniation, disc height, and clinical symptom scores. RESULTS: The interobserver and intraobserver reliability showed substantial to almost perfect agreement in the new Modic grading scoring system. The Modic grading score was positively correlated with intervertebral disc degeneration (r = 0.757, p < 0.001) and negatively correlated with the intervertebral disc height index (r = - 0.231, p < 0.001). There was no significant correlation between the Modic grading scoring system and disc herniation (r = 0.369, p = 0.249). Additionally, there was no significant correlation between the Modic grading score and the Japanese Orthopaedic Association score (r = - 0.349, p = 0.25), Oswestry Disability Index score (r = 0.246, p = 0.11), or visual analogue scale score (r = 0.315, p = 0.35). CONCLUSION: The new Modic grading scoring system had good interobserver and intraobserver reliability. The Modic grading score was positively correlated with intervertebral disc degeneration and negatively correlated with the intervertebral disc height.

Effect of Topical Nonsteroidal Anti-inflammatory Drugs Around the Incision on Postoperative Pain in Transforaminal Lumbar Interbody Fusion Surgery: A Double-blind Randomized Controlled Trial.

BACKGROUND: How to minimize postoperative pain following spinal surgery has been a great challenge. We hypothesized that topical nonsteroidal anti-inflammatory drugs (NSAIDs) around the incision could relieve postoperative pain following transforaminal lumbar interbody fusion (TLIF) surgery. OBJECTIVE: This study tested the effect of topical NSAIDs around the incision for pain management after TLIF surgery. STUDY DESIGN: A double-blind randomized controlled trial. SETTING: Qilu Hospital of Shandong University. METHODS: Eighty patients who underwent single-level TLIF surgery were randomized into 2 groups. The treatment group received postoperative topical NSAIDs around the incision. The control group received a postoperative topical placebo around the incision. All patients in both groups received postoperative patient-controlled analgesia (PCA) via an analgesia pump. The primary outcome measures were the amount of opioid consumption and pain measurement via the visual analog scale (VAS). The secondary outcome measures were the time of first analgesic demand, operation time, postoperative drain output, side effects of opioids, postoperative stay, and Oswestry Disability Index (ODI) score. RESULTS: The consumption of opioids in the treatment group was significantly less than in the control group at postoperative 12 hours, 12 to 24 hours, and 24 to 48 hours (P < 0.005). The VAS in the treatment group was significantly lower than those in the control group at all assessment times within 72 hours postoperative (P < 0.005). The time of first analgesic demand of PCA in the treatment group was significantly longer than that in the control group (P < 0.005). The side effects of opioids were significantly less in the treatment group than in the control group (P < 0.05). There was no significant difference in operation time, postoperative drain output, postoperative stay, and ODI between the 2 groups (P > 0.05). LIMITATIONS: This was a single-center study for single-level TLIF surgery. CONCLUSION: Postoperative topical NSAID around the incision is a highly effective and safe method for postoperative pain management following single-level TLIF surgery. In our study it reduced postoperative opioid requirements and prolonged the time of first analgesic demand with no increased side effects. KEY WORDS: Transforaminal lumbar interbody fusion, postoperative pain, NSAID, topical NSAID, nonsteroidal anti-inflammatory drug, loxoprofen.

Comparative study of preoperative sagittal alignment between patients with multisegment cervical ossification of the posterior longitudinal ligament and cervical spondylotic myelopathy.

BACKGROUND CONTEXT: Preoperative sagittal alignment is of great significance in the development of spinal deformities, degenerative diseases, preoperative planning, postoperative clinical evaluation, and functional recovery. However, few reports have focused on the difference in preoperative sagittal alignment between patients with ossification of the posterior longitudinal ligament (OPLL) and patients with cervical spondylotic myelopathy (CSM). PURPOSE: To compare preoperative sagittal alignment between patients with multisegment cervical OPLL and multilevel CSM. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: A total of 243 patients were included in this study. OUTCOME MEASURES: The outcome measures were the Japanese Orthopaedic Association (JOA) score, visual analog scale (VAS) score, number of hand actions in 10 seconds, hand-grip strength, C2 to C7 Cobb angle, C2 to C5 Cobb angle, C5 to C7 Cobb angle, C2 to C7 sagittal vertical axis, C7 slope, T1 slope, K-line, K-line tilt, and range of motion (ROM). METHODS: The outcome measures were calculated in the OPLL group and CSM group and the data were analyzed using the unpaired t-test, χ² test, and one-way analysis of variance. RESULTS: A total of 243 patients (136 men, 107 women; mean age, 59.1±10.6 years) underwent surgical treatment from September 2013 to December 2021. In total, 123 patients were diagnosed with multisegment cervical OPLL, including continuous type (n=39), segmental type (n=38), and mixed type (n=46). The remaining 120 patients had multisegment CSM. The disease course in the OPLL group was significantly shorter than that in the CSM group (p<.05). Among the above preoperative measurements, the JOA score, number of hand actions in 10 seconds, hand-grip strength, and VAS score were not significantly different between the two groups (p>.05). The C2 to C7 Cobb angle was significantly larger in the OPLL than CSM group (17.7°±9.2° and 14.9°±9.3°, respectively; p< .05), as was the C5 to C7 Cobb angle (10.0°±6.3° and 7.5°±6.1°, respectively; p<.05). The ROM was significantly smaller in the OPLL than CSM group (33.1°±8.1° and 40.1°±10.9°, respectively; p<.001). Within the OPLL group, the ROM was significantly smaller in the continuous type than in the segmental type (p<.05). CONCLUSION: Patients with multisegment cervical OPLL have greater lordotic preoperative sagittal alignment and smaller preoperative ROM than patients with CSM.

Safety and accuracy of cannulated pedicle screw placement in scoliosis surgery: a comparison of robotic-navigation, O-arm-based navigation, and freehand techniques.

PURPOSE: To compare the safety and accuracy of cannulated pedicle screw placement using a robotic-navigation technique, O-arm-based navigation technique, or freehand technique. METHODS: This study analyzed 106 consecutive patients who underwent scoliosis surgery. Thirty-two patients underwent robotic-navigation-assisted pedicle screw insertion (Group 1), 34 patients underwent O-arm-based navigation-guided pedicle screw insertion (Group 2), and 40 patients underwent freehand pedicle screw insertion (Group 3). The primary outcome measure was the accuracy of screw placement. Secondary outcome parameters included operation time, blood loss, radiation exposure, and postoperative stay. RESULTS: A total of 2035 cannulated pedicle screws were implanted in 106 patients. The accuracy rate of the first pedicle screw placement during operation was significantly greater in Group 1 (94.7%) than in Group 2 (89.2%; P < 0.001). The accuracy rate of pedicle screw placement postoperatively decreased in the order of Group 1 (96.7%) > Group 2 (93.0%) > Group 3 (80.4%; P < 0.01). There were no significant differences in blood loss or postoperative stay among the three groups (P > 0.05). The operation times of Group 1 and Group 2 were significantly longer than that of Group 3 (P < 0.05). CONCLUSION: The robotic-navigation and O-arm-based navigation techniques effectively increased the accuracy and safety of pedicle screw insertion alternative to the freehand technique in scoliosis surgery. Compared with the O-arm-based navigation technique, the robotic-navigation technique increases the mean operation time, but also increases the accuracy of pedicle screw placement. A three-dimensional scan after insertion of the K-wire may increase the accuracy of pedicle screw placement in the O-arm-based navigation technique.

Comparison of Clinical Outcomes of Cervical Laminoplasty for Cervical Spondylotic Myelopathy: Double-Door With Lamina Staple, Single-Door With Miniplate, and Double-Door With Spacer-A 2-Year Follow-Up Study.

BACKGROUND: There were few studies to compare the outcomes of different types of cervical laminoplasties. OBJECTIVE: To compare the clinical outcomes of double-door cervical laminoplasty with lamina staple (double-door staple), single-door cervical laminoplasty with miniplate (single-door miniplate), and double-door cervical laminoplasty with spacer (double-door spacer). METHODS: The study involved 166 patients with cervical spondylotic myelopathy (CSM). Fifty-two patients underwent double-door staple, 63 patients underwent single-door miniplate, and 51 patients underwent double-door spacer. The clinical outcomes were measured. RESULTS: There was no significant difference in Japanese Orthopedic Association score among the 3 groups ( P > .05). The operation time was significantly shorter in double-door staple and single-door miniplate groups than in the double-door spacer group ( P < .005). The estimated blood loss was significantly more in the single-door miniplate group than in double-door staple and double-door spacer groups ( P < .005). The expansion ratio of cervical intraspinal cross-sectional area decreased in the order of double-door staple > double-door spacer > single-door miniplate. There were no significant differences in the expansion ratio of dural sac cross-sectional area among the 3 groups. CONCLUSION: Double-door staple, double-door spacer, and single-door miniplate can achieve favorable clinical outcomes for CSM. The blood loss of double-door staple is less than that of single-door miniplate, and the operation time of double-door staple is shorter than that of double-door spacer. The mean expansion ratio of cervical intraspinal cross-sectional area decreased in the order of double-door staple > double-door spacer > single-door miniplate. Overall, double-door staple is a safe and innovative alternative choice for treatment of CSM.

How Sagittal Spinal Parameters Predict Anterolateral Spinal Ossification Severity: A Study Based on CT Classification.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: The purpose of this study was to establish a CT classification system of anterolateral spinal ossification and analyze the effects of sagittal spinal parameters on ossification. SUMMARY OF BACKGROUND DATA: Patients with diffuse idiopathic skeletal hyperostosis often present with anterolateral ossification of the spine. Few reports consider anterolateral spinal ossification at each spinal level or explore the influence of sagittal alignment. MATERIALS AND METHOD: One hundred and twenty patients (79 males and 41 females) over 60 years old who underwent whole spinal CT scans from October 2018 to November 2021 were analyzed. Volume rendering technique images were used to assess the degree of anterolateral spinal ossification in each intervertebral space, and a classification system was established. Sagittal parameters, such as thoracic kyphosis, lumbar lordosis (LL), cervical lordosis, sacral slope, and thoracolumbar junction angle of the patients were measured. Multifactor stepwise linear regression analysis and ordered logistic regression analysis were used to study the effects of the sagittal parameters on ossification grades. RESULTS: The median age of the study population was 67 years (63-72 IQR). The new classification system classifies the severity of anterolateral spinal ossification in each intervertebral space into grades 0 to 3 with an intra-observer intraclass correlation coefficient value of 0.909 and inter-observer intraclass correlation coefficient value of 0.900. Multivariate stepwise linear regression analysis showed that age (OR=1.30, P <0.001), weight (OR=1.23, P =0.013), and cervical lordosis (OR=1.19, P <0.001) were significantly correlated with total ossification grade. Multifactor ordered logistic regression analysis showed that there was a statistically significant correlation between cervical lordosis and the ossification grades of each intervertebral space of T1~T4 ( P ≤0.005), between thoracic kyphosis and each intervertebral space in T4~T12 ( P ≤0.019), and between thoracolumbar junction angle and each intervertebral space in T10~L3 ( P ≤0.025). LL was significantly and positively correlated with the ossification grades of each intervertebral space in T7~T11 ( P ≤0.041). LL and sacral slope were significantly negatively correlated with the ossification grades of each intervertebral space in L3~S1 ( P ≤0.047). CONCLUSION: Our new classification scheme demonstrated good accuracy and reliability for the evaluation of the severity of anterolateral spinal ossification. The effect of sagittal parameters on anterolateral spinal ossification was position-specific. The greater the kyphosis or the smaller the lordosis of a spinal region, the more severe the degree of ossification in the corresponding region. LEVEL OF EVIDENCE: 3.

Sacroiliac joint degeneration in degenerative lumbar spondylolisthesis and related risk factors: a retrospective study.

OBJECTIVE: This study was performed to evaluate the degree of radiological sacroiliac joint (SIJ) degeneration in patients with degenerative lumbar spondylolisthesis (DLS). The related risk factors for SIJ degeneration were also investigated. METHODS: We retrospectively analyzed the lumbar and pelvic computed tomography (CT) scans of 303 patients with DLS admitted from January 2018 to December 2021. One hundred and fifty-six age-, gender-, and body mass index-matched patients without lumbar anomality who underwent lower abdominal or pelvic computed tomography scans were included in the control group. Sagittal parameters were measured on full-length lateral radiographs. Two protocols (Backlund's grade and Eno's classification) were used to assess SIJ degeneration. Univariate analysis and bivariate and multivariate regression analysis were performed to identify the factors affecting SIJ degeneration in patients with DLS. RESULTS: According to Backlund's grade and Eno's classification, SIJ degeneration was more severe in the DLS group than in the control group (P < 0.001). Multi-segment degenerative changes (P = 0.032), two-level DLS (P = 0.033), a history of hysterectomy (P < 0.001), lower extremity pain (P = 0.016), and pelvic pain (P = 0.013) were associated with more significant SIJ degeneration as assessed by Backlund's grade. The results of Pearson's correlation analysis showed positive correlation between the sagittal vertical axis and SIJ degeneration (r = 0.232, P = 0.009). The multivariate linear regression analysis showed that a history of hysterectomy was significantly correlated with SIJ degeneration in patients with DLS (r = 1.951, P = 0.008). CONCLUSIONS: SIJ degeneration was more severe in patients with than without DLS. We should take SIJ degeneration into consideration when diagnosing and treating DLS especially those who had undergone previous hysterectomy or showed sagittal malalignment.

Comparison of robot-assisted versus fluoroscopy-assisted minimally invasive transforaminal lumbar interbody fusion for degenerative lumbar spinal diseases: 2-year follow-up.

This study was performed to prospectively compare the clinical and radiographic outcomes between robot-assisted minimally invasive transforaminal lumbar interbody fusion (RA MIS-TLIF) and fluoroscopy-assisted minimally invasive transforaminal lumbar interbody fusion (FA MIS-TLIF) in patients with degenerative lumbar spinal diseases. One hundred and twenty-three patients with lumbar degenerative diseases (lumbar spinal stenosis with instability and spondylolisthesis [degenerative spondylolisthesis or isthmic spondylolisthesis]) who underwent MIS-TLIF in our hospital were included in this study. Sixty-one patients underwent RA MIS-TLIF (Group A) and 62 patients underwent FA MIS-TLIF (Group B). Group A was further divided into Subgroup AI (46 single-level procedures) and Subgroup AII (15 double-level procedures). Group B was further divided into Subgroup BI (45 single-level procedures) and Subgroup BII (17 double-level procedures). The clinical outcome parameters were the visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, operative time, number of intraoperative fluoroscopies, blood loss, postoperative hospital stay, and postoperative complications. The radiographic change measures were the accuracy of screw placement, facet joint violation (FJV), fusion status, and change in disc height at the proximal adjacent segment at the 2-year follow-up. There were no significant differences in the VAS and ODI scores, blood loss, or postoperative hospital stay between Groups A and B (p > 0.05). The operative time was longer in Group A than B (p = 0.018). The operative time was longer in Subgroup AI than BI (p = 0.001). However, there was no significant difference between Subgroups AII and BII (p > 0.05). There was no significant difference in the number of intraoperative fluoroscopies for patients between Groups A and B (p > 0.05). Although the number of intraoperative fluoroscopies for patients was significantly higher in Subgroup AI than BI (p = 0.019), there was no significant difference between Subgroups AII and BII (p > 0.05). The number of intraoperative fluoroscopies for the surgeon was significantly lower in Group A than B (p < 0.001). For surgeons, the difference in the average number of intraoperative fluoroscopies between Subgroups AI and AII was 2.98, but that between Subgroups BI and BII was 10.73. In Group A, three guide pins exhibited drift and one patient developed a lateral wall violation by a pedicle screw. One pedicle screw perforated the anterior wall of the vertebral body and another caused an inner wall violation in Group B. The rate of a perfect screw position (grade A) was higher in Group A than B (p < 0.001). However, there was no significant difference in the proportion of clinically acceptable screws (grades A and B) between the two groups. The mean FJV grade was significantly higher in Group B than A (p < 0.001). During at 2-year postoperative follow-up, there was no significant difference in the fusion status between the two groups (p > 0.05); however, the decrease in disc height at the proximal adjacent segment was significantly less in Group A than B (p < 0.001). Robot-assisted percutaneous pedicle screw placement is a safer and more accurate alternative to conventional freehand fluoroscopy-assisted percutaneous pedicle screw insertion in MIS-TLIF.

Neurological Safety of Endoscopic Transforaminal Lumbar Interbody Fusion: A Magnetic Resonance Neurography Study.

OBJECTIVE: A magnetic resonance neurography (MRN) study was conducted to assess the neurological safety of endoscopic transforaminal lumbar intervertebral fusion (endo-TLIF). MATERIALS AND METHODS: A total of 56 healthy volunteers (29 men, 27 women; average age, 44 yr; age range, 21-60 yr) were included in the study. Coronal MRN images were collected from L2/L3 to L5/S1. The working triangle, modified working zone, and safest working zone areas, as well as the vertical and horizontal safe operation diameters, were measured. Linear regression analyses were conducted to explore the correlations between general characteristics (sex, age, height, body mass index) and the measured radiographic indicators. RESULTS: MRN can effectively evaluate the operation zone of endo-TLIF. The safest working zone, modified working zone, and working triangle areas were largest at L4/L5 (92.4±23.4, 136±35.6, and 197±41.7 mm 2 , respectively) and smallest at L2/L3 (45.5±12.9, 68.1±19.5, and 92.6±24.4 mm 2 , respectively). The vertical safe operation diameter was large at L4/L5 and L2/L3 (5.34±0.8 and 5.42±0.9 mm, respectively) and smallest at L5/S1 (2.94±0.9 mm). The horizontal safe operation diameter was large at L4/L5 (7.28±1.2 mm) and smaller at L5/S1 and L2/L3 (4.28±1.0 and 4.77±0.8 mm, respectively). CONCLUSIONS: L4/L5 has the lowest risk of nerve injury, and may be the safest level for beginners initiating endo-TLIF in their practice. We recommend that coronal MRN is routinely performed before endo-TLIF to minimize the risk of neurological injury.

Clinical Validity of 3 Different Grading Systems for Facet Joint Violation: A Retrospective Study and In-Depth Review.

STUDY DESIGN: Retrospective. OBJECTIVES: To study the violation rate of 3 different types of facet joint violation (FJV) grading systems (Babu, Shah, and Park), and to evaluate the accuracy, reliability, and association with clinical outcomes of the above 3 grading systems. METHODS: 152 patients of lumbar spinal stenosis treated with percutaneous pedicle screw placement were enrolled in our study. FJV was evaluated on 3-dimensional lumbar CT reconstruction. Three types of grading systems were used to evaluate FJV: Babu's system (grading by the severity of violation), Shah's system (grading by side of violation), and modified Park's system (grading by different components to cause violation). The violation rate and observer consistency of the 3 grading systems were analyzed. Clinical outcomes were evaluated by visual analog score (VAS), Oswestry disability index (ODI) score. RESULTS: Kappa coefficients of interobserver consistency on Babu, Shah, and Park grading systems were 0.726,0.849,0.692, respectively. The violation rate of Babu, Shah, and Park grading systems were comparable, which were 34.54%, 32.57%, 33.55%, respectively. In all 3 grading systems, the postoperative VAS low-back pain and ODI scores in non-FJV groups were lower than those in FJV groups (P < .05), and there were no significant differences between 2 groups in VAS leg pain(P >.05). CONCLUSIONS: Babu, Shah and modified Park grading system are reliable grading systems, and it reported comparable violation rate. The self-reported clinical outcomes of patients with FJV were worse at 2-year follow-up. For clinical application, it is recommended to use 2 or even 3 different grading systems together to evaluate the FJV.

Posterior Temporary C1-2 Pedicle Screws Fixation for the Treatment of Unstable C1-2 Complex Fractures: Minimum of 2-Year Follow-Up.

STUDY DESIGN: Retrospective. OBJECTIVES: To present rarely reported complex fractures of the upper cervical spine (C1-C2) and discuss the clinical results of the posterior temporary C1-2 pedicle screws fixation for C1-C2 stabilization. METHODS: A total of 19 patients were included in the study (18 males and 1 female). Their age ranged from 23 to 66 years (mean age of 39.6 years). The patients were diagnosed with complex fractures of the atlas and the axis of the upper cervical spine and underwent posterior temporary C1-2 pedicle screws fixation. The patients underwent a serial postoperative clinical examination at approximately 3, 6, 9 months, and annually thereafter. The neck disability index (NDI) and the range of neck rotary motion were used to evaluate the postoperative clinical efficacy of the patients. RESULTS: The average operation time and blood loss were 110 ± 25 min and 50 ± 12 ml, respectively. The mean follow-up was 38 ± 11 months (range 22 to 60 months). The neck rotary motion before removal, immediately after removal, and the last follow-up were 68.7 ± 7.1°, 115.1 ± 11.7°, and 149.3 ± 8.9° (P < 0.01). The NDI scores before and after the operation were 42.7 ± 4.3, 11.1 ± 4.0 (P < 0.01), and the NDI score 2 days after the internal fixation was removed was 7.3 ± 2.9, which was better than immediately after the operation (P < 0.01), and 2 years after the internal fixation was removed. The NDI score was 2.0 ± 0.8, which was significantly better than 2 days after the internal fixation was taken out (P < 0.001). CONCLUSIONS: Posterior temporary screw fixation is a good alternative surgical treatment for unstable C1-C2 complex fractures.