Long-Term Incidence of Adjacent Segmental Pathology After Minimally Invasive vs. Open Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare the incidence of adjacent segmental pathology (ASP) following minimally invasive (MI) vs open transforaminal lumbar interbody fusion (TLIF) and to identify factors linked to ASP requiring reoperation. METHODS: This retrospective study reviewed the outcomes of patients who underwent MI-TLIF or open TLIF. Radiographic ASP (RASP) was evaluated using X-ray imaging to distinguish between degenerative changes, spondylolisthesis, and instability in the adjacent spinal segment. Clinical ASP (CASP) was assessed with the visual analog scale score for leg and back pain and the Oswestry disability index. Patient data were collected 1, 2, 5, and 10 years postoperatively. The timing and frequency of ASP reoperation were analyzed. RESULTS: Five years postoperatively, the RASP rate was 35.23% and 45.95% in the MI-TLIF and open TLIF groups. The frequency of CASP differed significantly between the MI-TLIF and open TLIF groups at 1 year postoperatively. The rates of RASP, CASP, and ASP necessitating reoperation were not significantly different 10 years postoperatively. Cranial facet violation significantly affected ASP in both groups. In the open TLIF group, preoperative adjacent segment disc degeneration significantly influenced ASP. CONCLUSION: The RASP rate at 5 years postoperatively and the CASP rate at 1 year postoperatively differed significantly between groups. There was no difference in the rate of ASP requiring reoperation. Cranial facet violation is a crucial driving factor for ASP after both surgical procedures.

Risk Factors and Characteristics of In-Hospital Falls After Spine Surgery: A Retrospective, Single-Center Cohort Study in the Republic of Korea.

Background: Falls after orthopaedic surgery can cause serious injuries, which lengthen hospital stays and increase medical expenses. This has prompted hospitals to implement various fall-prevention protocols. The aims of this study were to determine the incidence of in-hospital falls after spine surgery, to analyze the overall risk factors, to discern factors that have a major influence on falls, and to evaluate the effectiveness of the fall-prevention protocol that we implemented. Methods: This was a retrospective, single-center study including patients who underwent spine surgery from January 2011 to November 2021 at the National Health Insurance Service Ilsan Hospital (NHISIH) in Goyang, Republic of Korea. Reported falls among these patients were examined. Patient demographics; surgery type, date, and diagnosis; and fall date and time were evaluated. Results: Overall, 5,317 spine surgeries were performed, and 128 in-hospital falls were reported (overall incidence: 2.31%). From the multivariable analyses, older age and American Society of Anesthesiologists (ASA) score were identified as independent risk factors for in-hospital patient falls (multivariable adjusted hazard ratio [aHR] for age 70 to 79 years, 1.021 [95% confidence interval (CI), 1.01 to 1.031]; for age ≥80 years, 1.035 [1.01 to 1.06]; and for ASA score of 3, 1.02 [1.01 to 1.031]). Similar results were seen in the subgroup who underwent primary surgery. Within 2 weeks following surgery, the highest frequency of falls occurred at 3 to 7 days postoperatively. The lowest fall rate was observed in the evening (6 to 10 p.m.). Morbidities, including rib, spine, and extremity fractures, were recorded for 14 patients, but none of these patients underwent operative treatment related to the fall. The NHISIH implemented a comprehensive nursing care service in May 2015 and a fall protocol in May 2017, but the annual incidence rate did not improve. The fall rate was higher after thoracolumbar surgeries (2.47%) than after cervical surgeries (1.20%). Moreover, a higher fall rate was observed in thoracolumbar cases with a greater number of fusion levels and revision spine surgeries. Conclusions: Patients with advanced age, more comorbidities, a greater number of fusion levels, and revision surgeries and who are female are more vulnerable to in-hospital falls after spine surgery. Novel strategies that target these risk factors are warranted. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Proximity Between Screw and Endplate of Upper Instrumented Vertebra Using a Cortical Bone Trajectory Screw can Increase Radiographic Adjacent Segment Degeneration Risks in Patients With Lumbar Spinal Stenosis.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: To determine the proximity between screw and endplate of the upper instrumented vertebra (UIV) using a cortical bone trajectory (CBT) screw as a predictive factor for radiographic adjacent segment degeneration (ASD) in patients surgically treated with transforaminal lumbar interbody fusion (TLIF) with CBT screws (CBT-TLIF) with lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: The risk factors for radiographic ASD after CBT-TLIF remain unknown. METHODS: Among patients surgically treated with CBT-TLIF at a single institute, 239 consecutive patients (80 males and 159 females) were enrolled. ASD was defined by the presence of one or more of the following three radiologic criteria on the adjacent segment: >3 mm anteroposterior translation, >10° segmental kyphosis, or >50% loss of disc height comparing immediate postoperative and 1-year follow-up radiographs. Clinical and radiological features associated with the development of ASD were retrospectively measured. Univariate and multivariate analyses were performed to identify risk factors associated with radiographic ASD. RESULTS: Radiographic ASD was observed in 71 (29.7%) cases at 1-year postoperative follow-up. The preoperative Pfirrmann grade of the adjacent segment (>grade 2), multi-level fusion (>2 levels), and proximity between the tip of CBT screws and endplate on the UIV were significantly associated with radiographic ASD (OR = 3.98, 95% CI [1.06-15.05], P=0.042 versus OR = 3.03, 95% CI [1.00-9.14], P=0.049 versus OR = 0.53, 95% CI [0.40-0.72], P<0.001). The cut-off value of the distance between the tip of the screw and endplate on UIV for radiographic ASD was approximately 2.5 mm (right-sided CBT screw; cut-off value 2.48 mm/ left-sided CBT screw; cut-off value 2.465 mm). CONCLUSION: Radiographic adjacent segment degeneration progression can occur when the cortical trajectory bone screw is close to the endplate of the upper instrumented vertebrae in patients with lumbar spinal stenosis undergoing fusion surgery.

Evaluation of the Fusion Rate and Safety of Escherichia coli-Derived rhBMP-2 in Transforaminal Lumbar Interbody Fusion for Patients with Degenerative Lumbar Disease: A Prospective, Multicenter, Single-Arm Trial.

Background: Few studies have documented the viability of E. coli-derived recombinant human bone morphogenetic protein-2 (rhBMP-2) in transforaminal lumbar interbody fusion (TLIF). This study aimed to assess the safety and fusion rate of rhBMP-2 in TLIF. Methods: The study was conducted as a prospective, multicenter, single-arm trial, and 30 patients needing one- or two-level TLIF were enrolled. Fusion rate was assessed using the 12-month interbody fusion rate on CT. Postoperative problems, including seroma, radiculitis, and ectopic bone formation, which have been documented as risks associated with rhBMP-2 in prior studies, were recorded. Results: The study demonstrated fusion outcomes in all instances at 52 and 104 weeks post-surgery. Significant improvements were observed in clinical outcomes, with ODI, SF-36, and VAS scores, all achieving statistical significance (p < 0.0001). No perioperative adverse events requiring reoperation were reported, and there were no incidences of seroma, radiculitis, cage migration, grafted bone extrusion, postoperative neurologic deficit, or deep wound infection. Conclusions: The study demonstrates the high safety and efficacy in inducing bone fusion of E. coli-derived rhBMP-2 in TLIF, with a notable absence of adverse postoperative complications. Trial registration: This study protocol was registered at Korea Clinical Research Information Service (number identifier: KCT0004738) on July 2020.

Clinical and radiological outcomes of non-window-type bioactive glass-ceramic cage in single-level ACDF versus PEEK cage filled with autologous bone.

Bioactive glass-ceramic (BGC) cage is a substitute for polyether ether ketone (PEEK) cages in anterior cervical discectomy and fusion (ACDF). Only a few comparative studies exist using PEEK and non-window-type BGC cages (CaO-SiO2-P2O5-B2O3) in single-level ACDF. This study compared PEEK cages filled with autologous iliac bone grafts and BGC cages regarding clinical safety and effectiveness. A retrospective case series was performed on 40 patients who underwent single-level ACDF between October 2020 and July 2021 by a single orthopedic spine surgeon. The spacers used in each ACDF were a PEEK cage with a void filled with an autologous iliac bone graft and a non-window-type BGC cage in 20 cases. The grafts were compared pre-operatively and post-operatively at 6 weeks and 3, 6, and 12 months. Post-operative complications were investigated in each group. Clinical outcome was measured, including Visual Analog Scale (VAS) scores of neck and arm pains, Japanese Orthopedic Association score (JOA), and Neck Disability Index (NDI). Dynamic lateral radiographs were used to assess the inter-spinous motion (ISM) between the fusion segment and subsidence. The fusion status was evaluated using a computed tomography (CT) scan. Overall, 39 patients (19 and 20 patients in the PEEK and BGC groups, respectively) were recruited. Eighteen (94.7%) and 19 (95.0%) patients in the PEEK and BGC groups, respectively, were fused 12 months post-operatively, as assessed by ISM in dynamic lateral radiograph and bone bridging formation proven in CT scan. The PEEK and BGC groups showed substantial improvement in neck and arm VAS, JOA, and NDI scores. No substantial difference was found in clinical and radiological outcomes between the PEEK and BGC groups. However, the operation time was considerably shorter in the BGC group than in the PEEK group. In conclusion, a non-window-type BCG cage is a feasible substitute for a PEEK cage with an autologous iliac bone graft in single-level ACDF.

Association of Functional Gastrointestinal Disorders with Adolescent Idiopathic Scoliosis.

Numerous adolescents diagnosed with adolescent idiopathic scoliosis (AIS) often manifest symptoms indicative of functional gastrointestinal disorders (FGIDs). However, the precise connection between FGIDs and AIS remains unclear. The study involved adolescents drawn from sample datasets provided by the Korean Health Insurance Review and Assessment Service spanning from 2012 to 2016, with a median dataset size of 1,446,632 patients. The AIS group consisted of individuals aged 10 to 19 with diagnostic codes for AIS, while the control group consisted of those without AIS diagnostic codes. The median prevalence of FGIDs in adolescents with AIS from 2012 to 2016 was 24%. When accounting for confounding factors, the analysis revealed that adolescents with AIS were consistently more prone to experiencing FGIDs each year (2012: adjusted odds ratio (aOR), 1.21 [95% confidence interval (CI), 1.10-1.35], p < 0.001; 2013: aOR, 1.31 [95% CI, 1.18-1.46], p < 0.001; 2014: aOR, 1.24 [95% CI, 1.12-1.38], p < 0.001; 2015: aOR, 1.34 [95% CI, 1.21-1.49], p < 0.001; and 2016: aOR, 1.35 [95% CI, 1.21-1.50], p < 0.001). These findings suggest that AIS is correlated with an elevated likelihood of FGIDs, indicating that AIS may function as a potential risk factor for these gastrointestinal issues. Consequently, it is recommended to provide counseling to adolescents with AIS, alerting them to the heightened probability of experiencing chronic gastrointestinal symptoms.

Risk of non-thyroidal autoimmune diseases in patients with Graves' disease: a nationwide retrospective cohort study.

OBJECTIVE: Graves' disease (GD) is a major autoimmune thyroid disorder and associated with non-thyroidal autoimmune disease (NTAD). We aimed to investigate the risk of NTAD in patients with GD compared with age- and sex-matched controls and to evaluate whether the risk differs between individuals with or without Graves' ophthalmopathy (GO). METHODS: This was a retrospective cohort study using data from the Korean National Health Claims database. We included 77 401 patients with GD (2,310 with GO) and 77 401 age- and sex-matched controls. Risk of NTAD were compared between the entire cohort and within the GD cohort. RESULTS: During a mean follow-up period of 9 years, NTAD developed in 12 341 (16.1%) patients in the GD cohort. Risk for systemic lupus erythematosus (SLE) [adjusted hazard ratio (aHR):1.15, 95% confidence interval (CI): 1.02-1.29], vitiligo (aHR: 1.24, 95% CI: 1.10-1.40), and alopecia areata (aHR: 1.11, 95% CI: 1.10-1.40) were higher in the GD cohort than in the control cohort. In the GD cohort, risk for SLE (aHR: 1.60, 95% CI: 1.11-2.33), Sjogren's syndrome (aHR: 1.89, 95% CI: 1.30-2.74), and ankylosing spondylitis (aHR: 1.53, 95% CI: 1.08-2.17) were higher in the GO group than in the non-GO group. CONCLUSION: This study demonstrated an increased risk of SLE, vitiligo and alopecia areata in patient with GD. In the GD cohort, patients with GO had an increased risk of SLE, Sjogren's syndrome and ankylosing spondylitis. These findings suggest that importance of implementing a strategy for early detection of NTAD based on the presence of GO.

Atmospheric environment and persistence of pediatric asthma: A population-based cohort study.

BACKGROUND: Asthma is a heterogeneous disease with different outcomes. For children with asthma at the age of 7 years, 67-75% are symptom-free as adults. Data on the important link between childhood and adult asthma are sparse. OBJECTIVE: We aimed to investigate factors associated with persistence of childhood asthma over three years of follow-up by linking data between Korea childhood Asthma Study (KAS) and their matched claims data from Health Insurance Review and Assessment Service (HIRA). METHODS: We analyzed data from 450 preadolescent children aged 7 to 10 years and classified them into remission or persistence groups. Baseline clinical characteristics and exposure to air pollution materials including PM2.5 and PM10 during three years of follow-up were compared. The main outcome was asthma persistence which was defined as the presence of asthma episodes with healthcare utilization and prescription of asthma medications within three years after KAS enrollment. RESULTS: At the third year of follow-up, after stepwise regression analysis, lower age at enrollment (adjusted odds ratio (aOR): 0.79; 95% confidence interval (CI): 0.64-0.96), male sex (aOR: 1.66; 95%CI: 1.05-2.63), proximity from an air-polluting facility (aOR: 2.4; 95%CI: 1.34-4.29), higher level outdoor PM2.5 (aOR: 1.1; 95%CI: 1.02-1.20), and higher rate of doctor-diagnosed food allergy (FA) (aOR: 2.33; 95%CI: 1.06-5.12) were significantly associated with persistence. CONCLUSION: We discovered various independent risk factors for the persistence of childhood asthma. By linking HIRA claims data, we could clarify risk factors for persistence in a well-defined study population.

Clinical Manifestations and Genotype of Primary Ciliary Dyskinesia Diagnosed in Korea: Multicenter Study.

PURPOSE: Primary ciliary dyskinesia (PCD) is a genetically heterogeneous disorder that leads to secondary ciliary dysfunction. PCD is a rare disease, and data on it are limited in Korea. This study systematically evaluated the clinical symptoms, diagnostic characteristics, and treatment modalities of pediatric PCD in Korea. METHODS: This Korean nationwide, multicenter study, conducted between January 2000 and August 2022, reviewed the medical records of pediatric patients diagnosed with PCD. Prospective studies have been added to determine whether additional genetic testing is warranted in some patients. RESULTS: Overall, 41 patients were diagnosed with PCD in 15 medical institutions. The mean age at diagnosis was 11.8 ± 5.4 years (range: 0.5 months-18.9 years). Most patients (40/41) were born full term, 15 (36.6%) had neonatal respiratory symptoms, and 12 (29.3%) had a history of admission to the neonatal intensive care unit. The most common complaint (58.5%) was chronic nasal symptoms. Thirty-three patients were diagnosed with transmission electron microscopy (TEM) and 12 patients by genetic studies. TEM mostly identified outer dynein arm defects (alone or combined with inner dynein arm defects, n = 17). The genes with the highest mutation rates were DNAH5 (3 cases) and DNAAF1 (3 cases). Rare genotypes (RPGR, HYDIN, NME5) were found as well. Chest computed tomography revealed bronchiectasis in 33 out of 41 patients. Among them, 15 patients had a PrImary CiliAry DyskinesiA Rule score of over 5 points. CONCLUSIONS: To our knowledge, this is the first multicenter study to report the clinical characteristics, diagnostic methods, and genotypes of PCD in Korea. These results can be used as basic data for further PCD research.

Effectiveness of Toothbrushing Technique for Biofilm Removal and Postoperative Infection Control after Spinal Fusion Surgery: A Retrospective Study.

This retrospective study was designed to investigate the effectiveness of using a toothbrush, which is commonly used in our daily life, for biofilm removal and infection control in the treatment of spinal infections occurring after spinal fusion surgery. Currently, a biofilm is thought to form on the surface of the metal inserted during spine fusion surgery. We aim to determine the differences in clinical outcomes between using and not using a toothbrush to remove biofilm while performing conventional drainage, curettage, and debridement. A total of 1081 patients who underwent anterior or posterior spinal fusion surgery between November 2018 and October 2022 were screened. The study included 60 patients who developed surgical site infection and underwent incision and drainage surgery either with a toothbrush (n = 20) or without a toothbrush (n = 40). Failure of infection control that requires revision surgery occurred in 2 patients (10%) in the Toothbrush group and in 14 patients (35%) in the No-Toothbrush group (p = 0.039). Thus, the rate of additional surgery was significantly lower in the Toothbrush group. Additionally, normalization of c-reactive protein levels occurred significantly faster in the Toothbrush group (p = 0.044). Therefore, using a toothbrush to treat spinal infections following spinal fusion surgery appears to have beneficial mechanical debridement effects, resulting in improved clinical results, which were also confirmed based on the electron microscopic images.

Novel limbal dermoid surgery for visual acuity and cosmesis improvement: A 7-year retrospective review.

BACKGROUND: To report a long-term outcome of the novel combined surgical method of complete excision, corneal tattooing, and a sutureless limbal conjunctival autograft for limbal dermoid. METHODS: All patients who were referred to our clinic for limbal dermoid, and underwent a combined surgery of complete excision, corneal tattooing, and a sutureless limbal conjunctival autograft were retrospectively reviewed. The surgery was performed by one surgeon, and all clinical information was obtained during a seven-year follow up period. In all patients, surgical outcomes of cosmesis, best corrected visual acuity (BCVA), spherical equivalent (SE), and corneal/ocular astigmatism were obtained and compared preoperatively and postoperatively. RESULTS: During seven years, 24 patients (24 eyes) with limbal dermoid were finally enrolled. The mean age was 10.1±8.9 years old. The surgery resulted in an improved appearing ocular surface in all cases without any complications. There was no statistical difference in BCVA, corneal and ocular astigmatism between preoperatively and postoperatively (p = 0.231, 0.156 and 0.475, respectively). The mean SE was 0.12±3.19D preoperatively, and -0.21±3.02 D postoperatively with statistical significance (p = 0.037). Mean follow up period was 54.50 ± 15.62 months. CONCLUSIONS: Based on the results of this study, our innovative surgical method which includes complete excision with corneal tattooing and limbal conjunctival autograft can be a simple and safe procedure that achieves long standing cosmesis with limbal dermoids.

Fetal growth rather than prematurity determines lung function in children with asthma.

BACKGROUND AND OBJECTIVE: Preterm birth or fetal growth has been associated with reduced lung function and asthma during childhood in the general population. We aimed to elucidate whether prematurity or fetal growth has a significant influence on lung function or symptoms in children with stable asthma. METHODS: We included children with stable asthma who participated in the Korean childhood Asthma Study cohort. Asthma symptoms were determined by asthma control test (ACT). Percent predicted values of pre- and post-bronchodilator (BD) lung function including forced expiratory volume in 1 second (FEV1 ), forced vital capacity (FVC), and forced expiratory flow at 25%-75% of FVC (FEF25%-75% ) were measured. Lung function and symptoms were compared according to the history of preterm birth and birth weight (BW) for gestational age (GA). RESULTS: The study population consisted of 566 children (age range: 5-18 years). There were no significant differences in lung function and ACT between preterm and term subjects. We observed no significant difference in ACT but significant differences were observed in pre- and post-BD FEV1 , pre- and post-BD FVC, and post-BD FEF25%-75% according to BW for GA in total subjects. Two-way ANOVA revealed that BW for GA rather than prematurity was a significant determining factor for pre- and post-BD lung function. After regression analysis, BW for GA was still a significant determining factor of pre- and post-BD FEV1 and pre- and post-BD FEF25%-75% . CONCLUSION: Fetal growth rather than prematurity appears to have a significant effect on lung function in children with stable asthma.

Frequency of exacerbation and degree of required asthma medication can characterize childhood longitudinal asthma trajectories.

BACKGROUND: To the best of our knowledge, there have been no investigations of longitudinal asthma trajectories based on asthma exacerbation frequency and medications required for asthma control in children. OBJECTIVE: To investigate longitudinal asthma trajectories based on the exacerbation frequency throughout childhood and asthma medication ranks. METHODS: A total of 531 children aged 7 to 10 years were enrolled from the Korean childhood Asthma Study. Required asthma medications for control of asthma from 6 to 12 years of age and asthma exacerbation frequency from birth to 12 years of age were obtained from the Korean National Health Insurance System database. Longitudinal asthma trajectories were identified on the basis of asthma exacerbation frequency and asthma medication ranks. RESULTS: Four asthma clusters were identified: lesser exacerbation with low-step treatment (8.1%), lesser exacerbations with middle-step treatment (30.7%), highly frequent exacerbations in early childhood with small-airway dysfunction (5.7%), and frequent exacerbations with high-step treatment (55.6%). The frequent exacerbations with high-step treatment cluster were characterized by a high prevalence of male sex, increased blood eosinophil (counts) with fractional exhaled nitric oxide, and high prevalence of comorbidities. The highly frequent exacerbation in early childhood with small-airway dysfunction cluster was characterized by recurrent wheeze in preschool age, with high prevalence of acute bronchiolitis in infancy and a greater number of family members with small-airway dysfunction at school age. CONCLUSION: The present study identified 4 longitudinal asthma trajectories on the basis of the frequency of asthma exacerbation and asthma medication ranks. These results would help clarify the heterogeneities and pathophysiologies of childhood asthma.

The Clinical Use of Osteobiologic and Metallic Biomaterials in Orthopedic Surgery: The Present and the Future.

As the area and range of surgical treatments in the orthopedic field have expanded, the development of biomaterials used for these treatments has also advanced. Biomaterials have osteobiologic properties, including osteogenicity, osteoconduction, and osteoinduction. Natural polymers, synthetic polymers, ceramics, and allograft-based substitutes can all be classified as biomaterials. Metallic implants are first-generation biomaterials that continue to be used and are constantly evolving. Metallic implants can be made from pure metals, such as cobalt, nickel, iron, or titanium, or from alloys, such as stainless steel, cobalt-based alloys, or titanium-based alloys. This review describes the fundamental characteristics of metals and biomaterials used in the orthopedic field and new developments in nanotechnology and 3D-printing technology. This overview discusses the biomaterials that clinicians commonly use. A complementary relationship between doctors and biomaterial scientists is likely to be necessary in the future.

Assessment of Biomechanical Advantages in Combined Anterior-Posterior Cervical Spine Surgery by Radiological Outcomes: Pedicle Screws over Lateral Mass Screws.

BACKGROUND: The combined anterior-posterior approach has shown good clinical outcomes for multilevel cervical diseases. This work describes the biomechanical advantage of cervical-pedicle-screw fixation over lateral-mass-screw fixation in combined anterior-posterior cases. METHOD: Seventy-six patients who received combined cervical surgery from June 2013 to December 2020 were included. The patients were divided into two groups: the lateral-mass-screw group (LMS) and the pedicle-screw group (PPS). Radiological outcomes were assessed with lateral cervical spine X-rays for evaluating sagittal alignment, subsidence, and bone remodeling. RESULTS: At 1 year postoperatively, the numbers of patients whose C2-C7 cervical lordosis was less than 20 degrees decreased by more in the PPS group (p-value = 0.001). The amount of vertical-length change from immediately to 1 year postsurgery was less in the PPS group than in the LMS group (p-value = 0.030). The mean vertebral-body-width change was larger in the PPS group than in the LMS group during 3 months to 1 year postsurgery (p-value = 0.000). CONCLUSIONS: In combined anterior-posterior cervical surgery cases, maintenance of cervical lordosis and protection of the vertebral body from subsidence were better with the pedicle-screw fixation. More bone remodeling occurred when using the pedicle-screw fixation method.

Posterior Preventive Foraminotomy before Laminectomy Combined with Pedicle Screw Fixation May Decrease the Incidence of C5 Palsy in Complex Cervical Spine Surgery in Patients with Severe Myeloradiculopathy.

C5 palsy is a frequent sequela of cervical decompression surgeries for cervical myeloradiculopathy. Although many researchers have suggested various risk factors, such as cord shifting and the correction of lordotic angles, the tethering of the C5 root beneath the narrow foramen is an independent risk factor for C5 palsy. In this study, we tried to investigate different techniques for foramen decompression with posterior cervical fusion and assess the incidence of C5 palsy with each technique depending on the order of foraminal decompression. A combined 540° approach with LMS and uncovertebrectomy was used in group 1. Group 2 combined a 540° approach with pedicle screws and posterior foraminotomy, while posterior approach only with pedicle screws and foraminotomy was used in group 3. For groups 2 and 3, prophylactic posterior foraminotomy was performed before laminectomy. Motor manual testing to assess C5 palsy, the Neck Disability Index (NDI) and the Japanese Orthopedic Association (JOA) scores were determined before and after surgery. Simple radiographs, MRI and CT scans, were obtained to assess radiologic parameters preoperatively and postoperatively. A total of 362 patients were enrolled in this study: 208 in group 1, 72 in group 2, and 82 in group 3. The mean age was 63.2, 65.5, and 66.6 years in groups 1, 2, and 3, respectively. The median for fused levels was 4 for the three groups. There was no significant difference between groups regarding the number of fused levels. Weight, height, comorbidities, and diagnosis were not significantly different between groups. Preoperative JOA scores were similar between groups (p = 0.256), whereas the preoperative NDI score was significantly higher in group 3 than in group 2 (p = 0.040). Mean JOA score at 12-month follow-up was 15.5 ± 1.89, 16.1 ± 1.48, and 16.1 ± 1.48 for groups 1, 2, and 3, respectively; it was higher in group 3 compared with group 1 (p = 0.008) and in group 2 compared with group 1 (p = 0.024). NDI score at 12 months was 13, 12, and 13 in groups 1, 2, and 3, respectively; it was significantly better in group 3 than in group 1 (p = 0.040), but there were no other significant differences between groups. The incidence of C5 palsy was significantly lower in posterior foraminotomy groups with pedicle screws (groups 2 and 3) than in LMS with uncovertebrectomy (group 1) (p < 0.001). Thus, preventive expansive foraminotomy before decompressive laminectomy is able to significantly decrease the root tethering by stenotic lesion, and subsequently, decrease the incidence of C5 palsy associated with posterior only or combined posterior and anterior cervical fusion surgeries. Additionally, such expansive foraminotomy might be appropriate with pedicle screw insertion based on biomechanical considerations.

A Comparative Analysis of Bi-Portal Endoscopic Spine Surgery and Unilateral Laminotomy for Bilateral Decompression in Multilevel Lumbar Stenosis Patients.

The clinical and radiological results before and after surgery were compared and analyzed for patients with multilevel lumbar stenosis who underwent bi-portal endoscopic spine surgery (BESS) and microscopic unilateral laminotomy for bilateral decompression (ULBD). We retrospectively identified 47 and 49 patients who underwent BESS and microscopic ULBD, respectively, who were diagnosed with multi-level lumbar stenosis. Clinical outcomes were evaluated using the visual analog scale score for both back and leg pain, and medication (pregabalin) use and Oswestry Disability Index (ODI) scores for overall treatment outcomes were used pre-operatively and at the final follow-up. Radiological outcomes were evaluated as the percentage of dura expansion volume, and percentage preservation of both facets and both lateral recess angles. The follow-up period of patients was about 17.04 months in the BESS group and about 16.90 months in the microscopic ULBD group. The back and leg visual analog scale (VAS) scores and average pregabalin use decreased more significantly in the BESS group than in the microscopic ULBD group (each p-value 0.0443, <0.001, 0.0378). All radiological outcomes were significantly higher in the BESS group than in the ULBD group. The change in ODI in two-level spinal stenosis showed a significantly higher value in the BESS group compared to the microscopic ULBD group (p-value 0.0335). Multilevel decompression with the BESS technique in multiple spinal stenosis is an adequate technique as it shows better clinical and radiological results than microscopic ULBD during a short-term follow-up period.

Analyses of Foveal Avascular Zone in Patients with General Blunt Ocular Trauma Using Optical Coherence Tomography Angiography.

PURPOSE: To investigate the effect of blunt ocular trauma (BOT) on foveal circulation, and in particular the foveal avascular zone (FAZ), using optical coherence tomography angiography (OCTA). METHODS: This retrospective study consisted of 96 eyes (48 traumatized eyes and 48 nontraumatized eyes) from 48 subjects with BOT. We analyzed the FAZ area of deep capillary plexus (DCP) and superficial capillary plexus (SCP) immediately after BOT and at 2 weeks after BOT. We also evaluated the FAZ area of DCP and SCP in patients with and without blowout fracture (BOF). RESULTS: There were no significant differences in FAZ area between traumatized and nontraumatized eyes at DCP and SCP in the initial test. In traumatized eyes, the FAZ area at SCP was significantly reduced on follow-up when compared to initial test (p = 0.01). In case of eyes with BOF, there was no significant differences in FAZ area between traumatized and nontraumatized eyes at DCP and SCP on initial test. No significant difference of FAZ area was found on follow-up relative to the initial test, whether in the DCP or SCP. In case of eyes without BOF, there was no significant differences of FAZ area between traumatized and nontraumatized eyes at DCP and SCP in initial test. Also, no significant difference of FAZ area at DCP was found on follow-up test compared to initial test. However, the FAZ area at SCP was significantly reduced in follow-up test compared with that in the initial test (p = 0.04). CONCLUSIONS: Temporary microvascular ischemia occurs in the SCP of patients after BOT. Patients should be warned of transient ischemic changes that may occur after trauma. OCTA can provide useful information regarding the subacute changes in the FAZ at SCP after BOT, even without evident findings of structural damage on fundus examination.

A Comparison Between Cortical Bone Trajectory Screws And Traditional Pedicle Screws in Patients With Single-Level Lumbar Degenerative Spondylolisthesis: Five-Year Results.

STUDY DESIGN: A retrospective observational study. OBJECTIVE: This study investigated the clinical and radiological results of using cortical bone trajectory (CBT) screws versus traditional pedicle (TP) screws in transforaminal lumbar interbody fusion (TLIF) during a five-year follow-up of patients with single-level lumbar degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: Few studies have compared five-year follow-up outcomes between CBT screws and TP screws in TLIF. MATERIALS AND METHODS: We reviewed outcome data of patients with single-level lumbar degenerative spondylolisthesis who underwent TLIF procedures with CBT screws (131 patients) or TP screws (80 patients) between 2011 and 2015. Patient-reported clinical outcome data included Oswestry disability index scores and visual analog scale (VAS) scores for back and leg pain at baseline, six months, and one year, two years, and five years postoperatively. The radiographic fusion rate and prevalence of secondary surgery for adjacent segment disease were also measured. RESULTS: During the follow-up over five years, the CBT group had significantly lower VAS scores for back pain ( P <0.0001, respectively). At two years after surgery, the CBT group had significantly higher VAS scores for leg pain ( P =0.007). At five years postoperatively, no significant differences existed in the VAS score for leg pain or in the Oswestry disability index score between the two groups. Radiographic fusion rates (CBT vs. TP: 95.5% vs. 95.9%; P =0.881) and adverse events during the five years after surgery were not significantly different. At two years postoperatively, the prevalence of secondary surgery to treat adjacent segment disease was significantly different between the two groups (CBT vs . TP: 13.7% vs. 5.0%; P =0.044). CONCLUSIONS: Our results suggest that, during a five-year followup, CBT screws for TLIF were an effective treatment compared to TP screws in the setting of single-level lumbar degenerative spondylolisthesis. However, when using CBT screws for TLIF, surgeons should consider the higher rate of secondary procedures to treat symptomatic adjacent segment disease.