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.

Reliability of the EOS Imaging System for Assessment of the Spinal and Pelvic Alignment in the Sagittal Plane.

BACKGROUND: The sagittal alignment of the spine and pelvis is not only closely related to the overall posture of the body but also to the evaluation and treatment of spine disease. In the last few years, the EOS imaging system, a new low-dose radiation X-ray device, became available for sagittal alignment assessment. However, there has been little research on the reliability of EOS. The purpose of this study was to evaluate the intrarater and interrater reliability of EOS for the sagittal alignment assessment of the spine and pelvis. METHODS: Records of 46 patients were selected from the EOS recording system between November 2016 and April 2017. The exclusion criteria were congenital spinal anomaly and deformity, and previous history of spine and pelvis operation. Sagittal parameters of the spine and pelvis were measured by three examiners three times each using both manual and EOS methods. Means comparison t-test, Pearson bivariate correlation analysis, and reliability analysis by intraclass correlation coefficients (ICCs) for intrarater and interrater reliability were performed using R package "irr." RESULTS: We found excellent intrarater and interrater reliability of EOS measurements. For intrarater reliability, the ICC ranged from 0.898 to 0.982. For interrater reliability, the ICC ranged from 0.794 to 0.837. We used a paired t-test to compare the values measured by manual and EOS methods: there was no statistically significant difference between the two methods. Correlation analysis also showed a statistically significant positive correlation. CONCLUSIONS: EOS showed excellent reliability for assessment of the sagittal alignment of the spine and pelvis.

Comparison of postoperative pain control methods after bony surgery in the foot and ankle.

BACKGROUND: We performed a prospective study to evaluate and compare the effectiveness of postoperative pain control methods after bone surgery in the foot and ankle. METHODS: Among the patients who underwent foot and ankle surgery from June 2014 to September 2015 with an ultrasound-guided nerve block, 84 patients who fully completed a postoperative pain survey were enrolled. An opioid patch (fentanyl patch, 25mg) was applied in group A (30 patients). Diluted anesthetic (0.2% ropivacaine, 30ml) was injected into the sciatic nerve once, about 12h after the preoperative nerve block, in group B (27 patients). Periodic intramuscular injection of an analgesic (ketorolac [Tarasyn], 30mg) was performed in group C (27 patients). The visual analogue scale (VAS) pain scores at 6, 12, 18, 24, and 48h after surgery were checked, and the complications of all methods were monitored. RESULTS: The mean VAS pain score was lower in group B, with a statistically significant difference (P<.05) between groups A, B, and C at 12 and 18h after surgery. Four patients in group A experienced nausea and vomiting; however, no other patients complained of any complications or adverse effects. CONCLUSION: The ultrasound-guided injection of a diluted anesthetic into the sciatic nerve seemed to be the most useful method for controlling pain in the acute phase after bone surgery in the foot and ankle. The injection of the diluted anesthetic once on the evening of the day of surgery resulted in less postoperative pain in the patients. LEVEL OF EVIDENCE: II.

Comparison of Time to Operation and Efficacies of Ultrasound-Guided Nerve Block and General Anesthesia in Emergency External Fixation of Lower Leg Fractures (AO 42, 43, 44).

The present randomized controlled trial evaluated the usefulness of ultrasound (US)-guided nerve block (NB) for emergency external fixation of lower leg fractures, by investigating the time required before surgery and the clinical results stratified by the anesthesia method (US-guided NB or general anesthesia [GA]). From June 2014 to April 2016, 40 patients who had undergone emergency surgery for external fixator application were enrolled in the present study. We measured the lead time before the start of surgery after the decision to perform emergency surgery in both groups. The US-guided NB group included 17 males (85%) and 3 females (15%), with a mean age of 55.6 (range 33 to 77) years. Of these 20 patients, 12 (60%) had comorbidities such as diabetes mellitus, hypertension, and kidney-related disease. Fracture type 42, 43, and 44 in the AO classification were observed in 3 (15%), 12 (60%), and 5 (25%) cases, respectively. The mean interval before emergency surgery was 4.3 (range 2 to 6.25) hours in the US-guided NB group. In the GA group (n = 20 patients), the mean interval before emergency surgery was 9.4 (range 3 to 14) hours, and this difference was statistically significant (p < .001). In the US-guided NB group, no cases of anesthesia failure or unstable vital signs occurred during surgery. Also, no postoperative complications related to the anesthesia method, such as aggravation of the general condition, developed. In contrast, 1 case of postoperative atelectasis occurred in the GA group. Emergency external fixation with US-guided NB in patients with lower extremity trauma can be implemented in less time, regardless of the preoperative preparation, which is a requirement for GA.

Is It "In" or "Out"? The Optimal Fluoroscopic Views for Intraoperative Determination of Proper Lateral Mass Screw Placement.

STUDY DESIGN: Cadaveric. OBJECTIVE: Determine optimal fluoroscopic views for detecting cervical lateral mass screw (LMS) violations. SUMMARY OF BACKGROUND DATA: Single plane intraoperative x-rays are commonly used but frequently inadequate due to its complex trajectory. Fluoroscopy can be taken in multiple planes, but the ideal fluoroscopic view to assess malposition is not known: depending on the view, any given screw may look "in" or "out." METHODS: C3-6 LMS were inserted in three cadavers. To evaluate neuroforaminal violation, LMS were inserted into the foramen with the tip penetrating the anterior cortex by 0, 2, and 4 mm. To assess facet joint violation, LMS were inserted toward the subjacent facet joint with the tip penetrating the anterior cortex by 0 and 2 mm. Fluoroscopic views were taken 0°, 10°, 20°, 30°, and 40° to the lateral plane. Views were independently evaluated by three blinded spine surgeons. RESULTS: Twenty-degree oblique view correctly identified a 2 mm penetration into the neuroforamen in 79%, and a 4 mm penetration in 86%, for a sensitivity of 83% and specificity of 90%. Thirty-degree view had lower sensitivity (76%) but slightly higher specificity (93%). Twenty-degree and 30° views were significantly more sensitive than the other views. Zero-degree view correctly identified a 2 mm penetration into the facet joint in 93%, for a sensitivity of 93% and specificity of 92%. Ten-degree view had lower sensitivity (72%) but higher specificity (100%). The 0° view was significantly more sensitive than the other views. CONCLUSION: Twenty-degree and 30° oblique views significantly provided the most sensitive assessment of LMS potentially violating the neuroforamen, whereas the 0° neutral lateral view significantly provided the most sensitive assessment of facet violations. The specificities were also high (in the 90% range) for these views. We recommend the use of these views intraoperatively when assessing proper placement of LMS fluoroscopically. LEVEL OF EVIDENCE: N/A.

Lateral release and medial plication for recurrent patella dislocation.

PURPOSE: This study aims to report the long-term results of lateral release and medial plication in patients with recurrent patellar dislocation. METHODS: In this study, 31 patients who underwent surgery for recurrent patellar dislocation were retrospectively reviewed between 1994 and 2004. Among the 31 patients were 12 male and 19 female patients. The average age was 23.9 ± 4.8 years, and the mean follow-up period was 11.6 ± 2.4 years. RESULTS: Three patients had postoperative dislocations. The mean Kujala score significantly improved from 57.5 ± 13.2 points preoperatively to 89.2 ± 8.7 points at the final follow-up (P < 0.0001). The median Tegner activity score significantly improved from 3 (range, 1-5) at preoperative examination to 7 (range, 3-9) at the final follow-up (P < 0.0001). Ten patients were rated as excellent, 18 as good, 2 as fair, and 1 as poor. The congruence angle improved from 16.5° ± 3.0° to -2.8° ± 2.7°, and the lateral patellofemoral angle improved from -4.2° ± 1.9° to 8.2° ± 2.5°. There was no case of osteoarthritis at the final follow-up. CONCLUSIONS: Percutaneous lateral release and medial plication showed satisfactory results with limited morbidity in the long-term follow-up. This traditional method remains a simple and effective surgical procedure for recurrent patellar dislocation. LEVEL OF EVIDENCE: Therapeutic, Level IV.