Spinopelvic parameters in degenerative spondylolisthesis.

The purpose of this study was to compare various sagittal spinopelvic parameters between patients with and without degenerative lumbar spondylolisthesis (DLS). A total of 165 patients who underwent surgery for low back and/or radicular pain were divided into two groups: those without DLS (non-DLS group; n = 85) and those with DLS (DLS group; n = 80). In all sagittal spinopelvic parameters, no significant difference was found between the non-DLS and DLS groups. The mean pelvic incidence (PI) value of the DLS group (56.4°) was almost similar to that of the non-DLS group (57.5°). The cross-sectional ratio of lumbar musculature was significantly smaller in the DLS group than in thenon-DLS group (p = 0.046). Contrary to the results of previous studies, a high PI may not be a predisposing factor for DLS development. Atrophy of back extensor muscles may play a role in the pathogenesis of DLS.

A retrospective study to reveal the effect of surgical correction of cervical kyphosis on thoraco-lumbo-pelvic sagittal alignment.

PURPOSE: Recent studies suggest that cervical lordosis is influenced by thoracic kyphosis and that T1 slope is a key factor determining cervical sagittal alignment. However, no previous study has investigated the influence of cervical kyphosis correction on the remaining spinopelvic balance. The purpose of this study is to assess the effect of surgical correction of cervical kyphosis on thoraco-lumbo-pelvic alignment. METHODS: Fifty-five patients who underwent ≥2 level cervical fusions for cervical radiculopathy or myelopathy were included. All patients had regional or global cervical kyphosis, which was surgically corrected into lordosis. Radiographic measurements were made using whole spine standing lateral radigraphs pre- and postoperatively to analyze various sagittal parameters. The visual analogue scale (VAS) for neck pain and the neck disability index (NDI) were calculated. The paired t test was used to compare pre- and post-operative radiographic measures and functional scores. Correlations between changes in cervical sagittal parameters and those of other sagittal parameters were analyzed by Pearson's correlation method. RESULTS: Preoperative kyphosis (11.4° ± 8.3°) was corrected into lordosis (-9.3° ± 8.1°). The average fusion levels were 3.3 ± 1.0. With increasing C2-C7 lordosis after surgery (from -3.4° ± 10.0° to -15° ± 7.9°), C0-C2 lordosis decreased significantly (from -34.6° ± 8.2° to -27.7° ± 8.0°) (P < 0.001). Thoracic kyphosis (from 24.8 ± 13.9° to 33.5 ± 11.9°) and T1 slope (from 12.8° ± 7.9° to 20.4° ± 5.2°) significantly increased after surgery (P < 0.001). However, other parameters did not significantly change (P > 0.05). Neck pain VAS and NDI scores (31.8 ± 16.2) significantly improved (P < 0.001). The degree of increasing C2-C7 lordosis by surgical correction was negatively correlated with changes in both thoracic kyphosis and T1 slope (P < 0.01). CONCLUSIONS: Surgical correction of cervical kyphosis affects T1 slope and thoracic kyphosis, but not lumbo-pelvic alignment. These results indicate that the compensatory mechanisms to minimize positive sagittal malalignment of the head may occur mainly in the thoracic, and not in the lumbosacral spine.

Is it enough to stop distal fusion at L3 in adolescent idiopathic scoliosis with major thoracolumbar/lumbar curves?

PURPOSE: The choice of distal fusion level in adolescent idiopathic scoliosis (AIS) patients with major thoracolumbar or lumbar (TL/L) curves (Lenke type 3C, 5C, or 6C) remains debatable. One of the most controversial issues involves stopping the distal fusion at L3, which might result in an increased risk of decompensation but save more mobile spinal segments. The purpose of this study was to evaluate and compare the clinical and radiological outcomes of corrective surgery for AIS with major TL/L curves according to the distal fusion level. METHODS: 229 AIS patients with Lenke type 3C, 5C, or 6C curves that underwent corrective surgery were included. Patients were grouped according to distal fusion level, either L3 (group A) or L4 (group B), and followed up for over 2 years. Group A was further divided into lower end vertebra (LEV) and last touching vertebra (LTV). The SRS-22 score was used to assess clinical outcomes. All radiological parameters were assessed pre- and postoperatively by standing anteroposterior whole-spine radiographs. Clinical and radiological parameters were compared between the groups. RESULTS: Postoperative decompensation was found in 4.6 % (9/197) of group A patients and 9.3 % (3/32) of group B patients. This difference was not statistically significant (P = 0.258). No difference was found in the clinical and radiological parameters between the two groups either pre- or postoperatively. Subgroup analysis showed that the scoliosis correction rate and postoperative apical vertebral translation were lower in cases with an LEV ≤ L4 or LTV = L5 when the fusion stopped at L3 distally. The adjacent disc wedge angle was aggravated postoperatively in these cases, although this did not reach statistical significance. CONCLUSIONS: There is no difference in the radiological and clinical outcomes in AIS according to the distal fusion level. Major TL/L curve correction in AIS may be sufficient distally at L3 in cases with an LEV ≥ L3 and LTV ≥ L4. However, stopping fusion at L3 requires caution in LEV ≤ L4 or LTV = L5 patients, as this correction rate might be suboptimal and causes a possible progression of the adjacent disc wedge angle.

Comparison of Early Surgical Treatment With Conservative Treatment of Incomplete Cervical Spinal Cord Injury Without Major Fracture or Dislocation in Patients With Pre-existing Cervical Spinal Stenosis.

STUDY DESIGN: This was a retrospective comparative study. OBJECTIVE: The objective of this study was to evaluate the clinical outcomes of early surgical treatment (<24 h) and conservative treatment of incomplete cervical spinal cord injury (CSCI) without major fracture or dislocation in patients with pre-existing cervical spinal canal stenosis (CSCS). SUMMARY OF BACKGROUND DATA: The relative benefits of surgery, especially early surgical treatment, and conservative treatment for CSCI without major fracture or dislocation in patients with pre-existing CSCS remain unclear. Animal models of CSCI have demonstrated that early surgical decompression immediately after the initial insult may prevent or reverse secondary injury. However, the clinical outcomes of early surgery for incomplete CSCI in patients with pre-existing CSCS are still unclear. MATERIALS AND METHODS: The medical records and radiographic data of 54 patients admitted to our facility between 2005 and 2015 with American Spinal Injury Association (ASIA) impairment scale grade B or C and pre-existing CSCS without major fracture or dislocation were retrospectively reviewed. Thirty-three patients (mean age, 57.4±14.0 y) underwent early surgical treatment within 24 hours after initial trauma (S group), and 21 patients (mean age, 56.9±13.6 y) underwent conservative treatment (C group) performed by 2 spinal surgeons in accordance with their policies. The primary outcome was the degree of improvement in ASIA grade after 2 years. RESULTS: During the 2-year follow-up period, higher percentages of patients in the S group than in the C group showed ≥1 grade (90.9% vs. 57.1%, P=0.0051) and 2 grade (30.3% vs. 9.5%) improvements in ASIA grade. Multivariate analysis showed that treatment type, specifically early surgical treatment, was the only factor significantly associated with ASIA grade improvement after 2 years (P=0.0044). CONCLUSIONS: Early surgery yielded better neurological outcomes than conservative treatment in patients with incomplete CSCI without major fracture or dislocation and pre-existing CSCS. LEVEL OF EVIDENCE: Level III.

Subclinical gait disturbance and postoperative gait improvement in patients with degenerative cervical myelopathy.

This study aimed to evaluate the subclinical gait abnormalities and the postoperative gait improvements in patients with degenerative cervical myelopathy using three-dimensional gait analysis. We reviewed the gait analysis of 62 patients who underwent surgical treatment for degenerative cervical myelopathy. The asymptomatic gait group included 30 patients and the gait disturbance group included 32 patients who can walk on their own slowly or need assistive device on stairs. The step width (17.2 cm vs. 15.9 cm, P = 0.003), stride length (105.2 cm vs. 109.1 cm, P = 0.015), and double-limb support duration (13.4% vs. 11.7%, P = 0.027) improved only in the asymptomatic gait group. Preoperatively, the asymptomatic gait group exhibited better maximum knee flexion angle (60.5° vs. 54.8°, P = 0.001) and ankle plantarflexion angle at push-off (- 12.2° vs. - 6.5°, P = 0.001) compared to the gait disturbance group. Postoperatively, maximum knee flexion angle (62.3° vs. 58.2°, P = 0.004) and ankle plantarflexion angle at push-off (- 12.8° vs. - 8.3°, P = 0.002) were still better in the asymptomatic gait group, although both parameters improved in the gait disturbance group (P = 0.005, 0.039, respectively). Kinematic parameters could improve in patients with gait disturbance. However, temporospatial parameters improvement may be expected when the operative treatment is performed before apparent gait disturbance.

How Does Screw Migration or Fracture After Anterior Cervical Plate Fixation Affect the Radiographic and Clinical Outcomes?

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The objective of this article is to assess the effect of screw migration and fracture associated with anterior cervical plating on long-term radiographic and clinical outcomes. BACKGROUND DATA: Screw migration and breakage detected after anterior cervical discectomy/corpectomy and fusion with plating may cause various implant-related complications and reduce solid fusion rate. However, little is known about their long-term prognosis. MATERIALS AND METHODS: Medical records and radiographic data of 248 consecutive patients who underwent anterior cervical discectomy and fusion or anterior cervical corpectomy and fusion with a dynamic plating system and were followed up for ≥2 years were retrospectively reviewed. Patients who experienced screw migration or breakage were classified as screw failure group (SF group, n=25). Patients without screw loosening or fracture until the last follow-up were defined as the nonfailure group (NF group, n=223). Visual analogue scales for neck pain, arm pain, and neck disability index were assessed. Radiologic measurements were performed to analyze solid fusion. The solid union was defined as interspinous motion ≤1 mm on flexion/extension lateral x-rays. RESULTS: A number of levels fused was significantly associated with increased risk of screw failure (P<0.01). A total of 13 patients in the SF group achieved solid fusion at final follow-up, although fusion rates at all postoperative time points were significantly lower in the SF group than in the NF group, including at final follow-up (P<0.01). Failures in 23 (92%) screw failure patients developed at the lowermost instrumented vertebra. The SF and NF groups experienced similar degrees of neck pain, arm pain, and neck disturbance index scores. There were no cases of complete screw extrusion or related complications requiring revision surgery. CONCLUSION: Although screw failure increased the incidence of pseudarthrosis, it did not aggravate postoperative arm pain, neck pain, or neck disability. As failed implants rarely migrate to an extent that endangers tracheoesophageal structures, immediate removal is rarely necessary.

Surfer's Myelopathy : Case Series and Literature Review.

Three male patients diagnosed with surfer's myelopathy (19-30 years) were admitted to our hospital. All three patients were novice surfers showing a typical clinical course of rapid progression of paraplegia following the onset of back pain. Typical history and magnetic resonance imaging features indicated the diagnosis of surfer's myelopathy. Two patients received high-dose steroid therapy and the other was treated with induced hypertension. One patient treated with induced hypertension showed almost full recovery; however, two patients who received high-dose steroid therapy remained completely paraplegic and required catheterization for bladder and bowel dysfunction despite months of rehabilitation. Our case series demonstrates the potentially devastating neurological outcome of surfer's myelopathy; however, early recovery in the initial 24-72 hours of presentation can occur in some patients, which is in accordance with previous reports. Ischemic insult to the spinal cord is thought to play a crucial role in the pathophysiology of surfer's myelopathy. Treatment recommendations include hydration, induced hypertension, early spinal angiography with intra-arterial intervention, intravenous tissue plasminogen activator, and high-dose steroid therapy; however, there is no standardized treatment option available. Early recovery appears to be important for long-term neurological outcome. Induced hypertension for initial treatment can be helpful for improving spinal cord perfusion; therefore, it is important for early and long-term neurological recovery. Education and awareness are essential for preventing surfer's myelopathy and avoiding further deterioration of neurological function.

Multilevel posterior foraminotomy with laminoplasty versus laminoplasty alone for cervical spondylotic myelopathy with radiculopathy: a comparative study.

BACKGROUND CONTEXT: Conventional laminoplasty is useful for expanding a stenotic spinal canal. However, it has limited use for the decompression of accompanying neural foraminal stenosis. As such, an additional posterior foraminotomy could be simultaneously applied, although this procedure carries a risk of segmental kyphosis and instability. PURPOSE: The aim of this study was to elucidate the long-term surgical outcomes of additional posterior foraminotomy with laminoplasty (LF) for cervical spondylotic myelopathy (CSM) with radiculopathy. STUDY DESIGN/SETTING: A retrospective comparative study was carried out. PATIENT SAMPLE: Ninety-eight consecutive patients who underwent laminoplasty for CSM with radiculopathy between January 2006 and December 2012 were screened for eligibility. This study included 66 patients, who were treated with a laminoplasty of two or more levels and followed up for more than 2 years after surgery. OUTCOME MEASURES: The Neck Disability Index (NDI), Japanese Orthopedic Association (JOA) scores, JOA recovery rates, and visual analog scale (VAS) were used to evaluate clinical outcomes. The C2-C7 sagittal vertical axis distance, cervical lordosis, range of motion (ROM), and angulation and vertebral slippage at the foraminotomy level were used to measure radiological outcomes using the whole spine anterioposterior or lateral and dynamic lateral radiographs. METHODS: Sixty-six patients with CSM with radiculopathy involving two or more levels were consecutively treated with laminoplasty and followed up for more than 2 years after surgery. The first 26 patients underwent laminoplasty alone (LA group), whereas the next 40 patients underwent an additional posterior foraminotomy at stenotic neural foramens with radiating symptoms in addition to laminoplasty (LF group). In the LF group, the foraminotomy with less resection than 50% of facet joint to avoid segmental kyphosis and instability was performed at 78 segments (unilateral-to-bilateral ratio=57:21) and 99 sites. Clinical and radiographic data were assessed preoperatively and at 2-year follow-up and compared between the groups. RESULTS: The NDI, JOA scores, JOA recovery rates, and VAS for neck and arm pain were improved significantly in both groups after surgery. The improvement in the VAS for arm pain was significantly greater in the LF group (from 5.55±2.52 to 1.85±2.39) than the LA group (from 5.48±2.42 to 3.40±2.68) (p<.001). Although cervical lordosis and ROM decreased postoperatively in both groups, there were no significant differences in the degree of reduction between the LF and LA groups. Although the postoperative focal angulation and slippage were slightly increased in the LF group, this was not to a significant degree. Furthermore, segmental kyphosis and instability were not observed in the LF group, regardless of whether the patient underwent a unilateral or bilateral foraminotomy. CONCLUSIONS: Additional posterior foraminotomy with laminoplasty is likely to improve arm pain more significantly than laminoplasty alone by decompressing nerve roots. Also, performing posterior foraminotomy via multiple levels or bilaterally did not significantly affect segmental malalignment and instability. Therefore, when a laminoplasty is performed for CSM with radiculopathy, an additional posterior foraminotomy could be an efficient and safe treatment that improves both myelopathy symptoms and radicular arm pain.

What Is the Fate of Pseudarthrosis Detected 1 Year After Anterior Cervical Discectomy and Fusion?

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To investigate the consequences and appropriate management of pseudarthrosis after anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Pseudarthrosis is a frequent complication of ACDF and causes unsatisfactory results. Little is known about long-term prognosis of detecting pseudarthrosis 1 year after ACDF. METHODS: Eighty-nine patients with a minimum 2-year follow-up were included. ACDF surgery using allograft and plating was performed: single-level in 51 patients, two-level in 26 patients, and three-level in 12 patients. Presence of pseudarthrosis was evaluated 1 year postoperatively and then the nonunion segments were re-evaluated 2 years postoperatively. Demographic data were assessed to identify the risk factors associated with pseudarthrosis. A visual analogue scale for neck/arm pain and the Neck Disability Index were analyzed preoperatively and at 1 and 2 years postoperatively. RESULTS: Pseudarthrosis was detected in 29 patients (32.6%) 1 year postoperatively: 15of 51 patients after single-level surgery, 9 of 26 patients after two-level surgery, and 5 of 12 patients after three-level surgery. Only eight patients showed persistent nonunion at 2 years: 3 of 15 patients after single-level surgery, 3 of 9 after two-level surgery, and 2 of 5 after three-level surgery. The remaining 21 patients (72.4%) achieved bony fusion 2 years postoperatively without any intervention. Patients who underwent two-level or three-level ACDF had a significantly higher pseudarthrosis rate than those who underwent single-level ACDF, with odds ratios of 1.844 and 3.147, respectively. The improvements in visual analogue scale for neck pain and Neck Disability Index scores in the persistent nonunion group were significantly lower than those in the final union group at 2 years. CONCLUSION: Patients with pseudarthrosis detected 1 year postoperatively may be observed without any intervention because approximately 70% of them will eventually fuse by the 2-year point. Early revision could, however, be considered if the pseudarthrosis is associated with considerable neck pain after multilevel ACDF. LEVEL OF EVIDENCE: 3.

Bipolar Injury of the Clavicle.

Eleven patients with bipolar clavicle injuries, including dislocation of both ends of the clavicle, dislocation of the sternoclavicular joint with distal clavicle fracture, dislocation of the acromioclavicular joint with medial clavicle fracture, and segmental fracture of the clavicle, were retrospectively reviewed. The purpose of this study was to report the clinical outcomes and a literature review of bipolar clavicle injury. Nonoperative treatment was performed for 5 patients and surgical treatment for 6 patients. The fracture or dislocation of the lateral end of the clavicle was fixed with a hook plate, and closed reduction of the medial end was performed; if the dislocation was still present, open reduction and anterior sternoclavicular ligament repair was performed. Visual analog scale pain score, Constant score, active range of motion, and radiological images were evaluated. The mean visual analog scale pain score for all patients was 0.7±0.9 (range, 0-2). The mean Constant score for all patients was 89.7±7.6 (range, 72-96). The mean Constant score was 84.2±8.5 (range, 72-96) for conservatively treated patients and 94.3±1.9 (range, 92-96) for surgically treated patients. The mean Constant score was 83.4±7.2 (range, 72-92) for patients in whom optimal reduction of 1 or both ends was not achieved. Residual pain or deformity was seen in 5 patients. The authors suggest operative treatment of bipolar clavicle injuries in younger, active patients when anatomical reduction cannot be achieved and residual deformity, pain, or functional limitations are unacceptable. [Orthopedics. 2018; 41(5):e681-e688.].

Comparison of Revision Rates Due to Aseptic Loosening between High-Flex and Conventional Knee Prostheses.

PURPOSE: The purpose was to evaluate and compare the revision rate due to aseptic loosening between a high-flex prosthesis and a conventional prosthesis. MATERIALS AND METHODS: Two thousand seventy-eight knees (1,377 patients) with at least 2 years of follow-up after total knee arthroplasty were reviewed. Two types of implants were selected (LPS-Flex and LPS, Zimmer) to compare revision and survival rates and sites of loosened prosthesis component. RESULTS: The revision rate of the LPS-Flex (4.9%) was significantly higher than that of the conventional prosthesis (0.6%) (p＜0.001). The 5-, 10-, and 15-year survival rates were 98.9%, 96.2% and 92.0%, respectively, for the LPS-Flex and 99.8%, 98.5% and 93.5%, respectively, for the LPS. The survival rate of the high-flex prosthesis was significantly lower than that of the conventional prosthesis, especially in the mid-term period (range, 5 to 10 years; p=0.002). The loosening rate of the femoral component was significantly higher in the LPS-Flex prosthesis (p=0.001). CONCLUSIONS: The LPS-Flex had a higher revision rate due to aseptic loosening than the LPS prosthesis in the large population series with a long follow-up. The LPS-Flex should be used carefully considering the risk of femoral component aseptic loosening in the mid-term (range, 5 to 10 years) follow-up period after initial operation.

Is 1-stage Posterior Corpectomy More Favorable Compared With Decompression With Fusion to Control Thoracic Cord Compression by Metastasis?

STUDY DESIGN: A retrospective comparative study OBJECTIVE:: To compare 1-stage posterior corpectomy to decompression with fusion for the control of thoracic cord compression due to a metastatic tumor. SUMMARY OF BACKGROUND DATA: Thoracic cord compression by a metastatic tumor can cause back pain, paralysis, and urinary/bowel dysfunction and is generally treated by palliative decompressive surgery. However, no studies have assessed the advantages of 1-stage posterior corpectomy compared with decompression with fusion. METHODS: We studied 18 patients who underwent surgery for thoracic cord compression due to metastatic tumors between September 2009 and August 2013. Neurological examination was performed preoperatively and postoperatively. Data on operative time, blood loss during surgery, postoperative complications, and survival time were retrospectively retrieved from electronic medical records. Patients were divided into 2 groups based on treatment: decompression and corpectomy (corpectomy group, n=8) and decompression with fusion (decompression-fusion group, n=10). Data were statistically compared between the 2 groups. RESULTS: The mean age of the patients was 61±12 years. Motor weakness and urinary/bowel dysfunction were observed in 15 and 9 cases, respectively. Five patients, who could walk before surgery, could walk at 1 month following surgery. However, only 3 of the 13 patients who could not walk before surgery regained the ability to walk. No difference was found in the degree of muscle strength recovery between the 2 groups. However, the corpectomy group showed higher blood loss (2200 vs. 710 mL, P=0.037) and longer operative time (281 vs. 217 min, P=0.029) than the decompression-fusion group. CONCLUSIONS: There is no significant advantage of 1-stage posterior corpectomy over decompression with fusion. Furthermore, more blood loss and longer operative time may increase the risk of postoperative complications following corpectomy. For this reason, 1-stage posterior corpectomy to control thoracic metastasis should be considered with caution.

Can an Anchored Cage be Substituted for an Anterior Cervical Plate and Screw for Single-Level Anterior Cervical Fusion Surgery?: Prediction of Poor Candidates Through a Review of Early Clinical and Radiologic Outcomes.

STUDY DESIGN: This is a case series of device failure patients. OBJECTIVE: To identify poor candidates for anterior cervical discectomy and fusion (ACDF) using an anchored cage. SUMMARY OF BACKGROUND DATA: An anchored cage has been used as an alternative implant for ACDF surgery because of ease of use, relatively acceptable fusion rate, and lower risk of plate-related complications, including dysphagia. MATERIALS AND METHODS: We retrospectively reviewed the outcomes of 36 patients who underwent ACDF using an anchored cage between January 2012 and December 2013. The initial diagnoses included 8 traumatic soft disk herniations without posterior ligamentous complex injury, 25 degenerative soft disk herniations, 1 degenerative foraminal stenosis, 1 traumatic soft disk herniation after reducing a unilaterally dislocated facet joint, and 1 subluxation of a previously implanted cervical artificial disk. We encountered 5 cases with poor outcomes and performed 3 revisions on the index level. We reviewed the clinical and radiologic data for 31 patients with reasonable outcomes and reviewed the failed 5 cases separately. RESULTS: Among the 31 patients with reasonable outcomes, all the clinical parameters improved. For the radiologic outcomes, 10 cases of cage subsidence occurred and no patient experienced instability.Among the 5 patients with poor outcomes, 1 patient had traumatic soft disk herniation and a reduced unilaterally dislocated facet joint, 1 patient had subluxation of a previously implanted cervical artificial disk, and 3 patients had degenerative soft disk herniation and poor bone quality. Although 3 patients required revision surgeries, 2 patients showed only radiologic failures without revision. CONCLUSIONS: We analyzed the short-term outcomes of ACDF using an anchored cage and observed 5 patients with poor outcomes among 36 patients. We recommend the use of a single anchored cage for patients with definite evidence of posterior column stability and healthy bone. LEVEL OF EVIDENCE: Level 3.

Can C3 Laminectomy Reduce Interlaminar Bony Fusion and Preserve the Range of Motion After Cervical Laminoplasty?

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To investigate whether the resection of C3 lamina during cervical laminoplasty can prevent C2-C4 interlaminar bony fusion and preserve the range of motion (ROM) postoperatively. SUMMARY OF BACKGROUND DATA: Interlaminar bony fusion is a common complication after cervical laminoplasty, especially in the C2-C4. Laminectomy, rather than laminoplasty, of C3 has been recently introduced. Its advantages include minimizing muscle detachment at C2 and reducing postoperative neck pain. METHODS: A total of 59 patients with cervical spondylotic myelopathy that involved three or more levels, including C3, were consecutively treated with laminoplasty and followed up for more than 3 years after surgery. The first 45 patients underwent open-door laminoplasty at C3 (Lp group) and the subsequent 14 patients underwent laminectomy at C3 rather than laminoplasty (Ln group). The Lp group was further divided into two subgroups based on the development of interlaminar bony fusion at C2-C3 and/or C3-C4: Lp-NF (nonfusion) and Lp-F (fusion) groups. Clinical outcomes and radiographic parameters were assessed pre- and postoperatively. RESULTS: Nineteen out of 45 patients who underwent laminoplasty demonstrated fusion at 3-year follow up. Fusion developed more commonly in those patients who had a smaller preoperative ROM at C2-C4 segments (Lp-F 14.3°â€Š±â€Š6.9° vs. Lp-NF 21.4°â€Š±â€Š5.3°, P = 0.013). The neck disability index (range, 13.4 ±â€Š7.3 to 6.3 ±â€Š5.2, P < 0.001), visual analog scale for neck pain (range, 2.5 ±â€Š1.7 to 0.9 ±â€Š1.3, P = 0.027), Japanese Orthopedic Association (JOA) score (range, 14.3 ±â€Š1.9 to 16.0 ±â€Š2.4, P < 0.001), and JOA recovery rate (63.4 ±â€Š19.8%) in the Ln group improved postoperatively; however, there was no significant difference in the improvement of these clinical outcomes among all three groups. Postoperative cervical ROM was significantly reduced in all groups; however, the extent of reduction was significantly smaller in the Ln group (10.5°; range, 44.2°â€Š±â€Š9.1° to 33.7 ±â€Š6.0°) than in the Lp-NF (15.1°; range, 45.4°â€Š±â€Š8.5° to 30.3°â€Š±â€Š7.4°) or Lp-F (18.2°; range, 39.6°â€Š±â€Š9.3° to 21.4°â€Š±â€Š10.3°) groups (P < 0.05). CONCLUSION: C3 laminectomy with laminoplasty can prevent interlaminar bony fusion at C2-C4 and, ultimately, result in better preservation of cervical ROM than C3 laminoplasty. Furthermore, it yields similar clinical outcomes when compared with C3 laminoplasty. LEVEL OF EVIDENCE: 3.

Agreement on the Level Selection in Laminoplasty among Experienced Surgeons: A Survey-Based Study.

STUDY DESIGN: Survey based study. PURPOSE: To assess the degree of agreement in level selection of laminoplasty (LP) for the selected cervical myeloradiculopathy cases between experienced spine surgeons. OVERVIEW OF LITERATURE: Although, cervical LP is a widely used surgical technique for multi-level spinal cord compression, until now there is no consensus about how many segments or which segments should be opened to achieve a satisfactory decompression. METHODS: Thorough clinical and radiographic data (plain X-ray, computed tomography, and magnetic resonance imaging) of 30 patients who had cervical myelopathy were prepared. The data were provided to three independent spine surgeons with over 10 years experience in operation of their own practices. They were questioned about the most preferable surgical method and suitable decompression levels. The second survey was carried out after 6 months with the same cases. If the level difference between respondents was a half level or below, agreement was considered acceptable. The intraobserver and interobserver agreements in level selection were assessed by kappa statistics. RESULTS: Three respondents selected LP as an option for 6, 8, and 22 cases in the first survey and 10, 21, and 24 cases in the second survey. The reasons for selection of LP were levels of ossification of the posterior longitudinal ligament (p=0.004), segmental kyphotic deformity (p=0.036) and mean compression score (p=0.041). Intraobserver agreement showed variable results. Interobserver agreement was poor to fair by perfect matching (kappa=0.111-0.304) and fair to moderate by acceptable matching (kappa=0.308-0.625). CONCLUSIONS: The degree of agreement for level selection of LP was not high even though experienced surgeons would choose the opening segments on the basis of same criteria. These results suggest that more specific guidelines in determination of levels for LP should be required to decrease unnecessary wide decompression according to individual variance.

Patterns of Treatment for Metastatic Pathological Fractures of the Spine: The Efficacy of Each Treatment Modality.

BACKGROUND: Metastatic pathological fractures of the spine are a major problem for cancer patients; however, there is no consensus on treatment strategy. The purpose of this study was to evaluate various treatment options by analyzing their patterns for metastatic pathological fractures of the spine. METHODS: In this study, 54 patients (male:female = 36:18) who were diagnosed with metastatic pathological fractures of spine were recruited. Demographic data, origin of cancer, type of treatment, and results were obtained from electronic medical records. Treatment options were divided into radiotherapy (RT), vertebroplasty (VP) or kyphoplasty (KP), operation (OP), and other treatments. Treatment results were defined as aggravation, no response, fair response, good response, and unknown. The survival time after detection of pathologic fractures was analyzed with the Kaplan-Meier method. RESULTS: The mean age of the patients was 62.3 years. Hepatocellular carcinoma was the most common cancer of primary origin (n = 9), followed by multiple myeloma (n = 8). RT was the most common primary choice of treatment (n = 29, 53.7%), followed by OP (n = 13, 24.1%), and VP or KP (n = 10, 18.5%). Only 13 of 29 RT cases and 7 of 13 OP cases demonstrated a fair or good response. The mean survival time following detection of pathological spinal fractures was 11.1 months for 29 patients, who died during the study period. CONCLUSIONS: RT was the most common primary choice of treatment for metastatic pathological fractures of the spine. However, the response rate was suboptimal. Although OP should be considered for the relief of mechanical back pain or neurologic symptoms, care should be taken in determining the surgical indication. VP or KP could be considered for short-term control of localized pain, although the number of cases was too small to confirm the conclusion. It is difficult to determine the superiority of the treatment modalities, hence, a common guideline for the diagnosis and treatment of metastatic pathological fractures of the spine is required.

Lumbar Cryptococcal Osteomyelitis Mimicking Metastatic Tumor.

Cryptococcus is an encapsulated, yeast-like fungus that rarely causes infection in immunocompetent patients. We present the case report of a 66-year-old female patient with a history of rectal cancer with an isolated lumbar vertebral cryptococcosis proven by biopsy performed during operation. The patient was not an immunocompromised host and did not have any other risk factors except the history of cured rectal cancer. The presumptive diagnosis based on imaging studies was metastatic spine cancer, so operation was performed. However, cryptococcal osteomyelitis was diagnosed in the pathologic examination. This case report emphasizes that we should be aware that lumbar cryptococcosis can be a rare cause of mimicking lesions with metastatic cancer.

The clinical importance of lumbosacral transitional vertebra in patients with adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective review of radiographs. OBJECTIVE: The objective of this study was to (1) determine the prevalence of lumbosacral transitional vertebra (LSTV) with computed tomography (CT) and (2) correlate LSTV presence with lumbar disc degeneration at each level by magnetic resonance imaging. SUMMARY OF BACKGROUND DATA: LSTV is a frequently observed abnormality. Although its prevalence in patients with adolescent idiopathic scoliosis (AIS) has been shown, no studies have yet examined the clinical importance of LSTV in patients with AIS. METHODS: This study included 385 consecutive patients who underwent surgery for AIS at a single center. Plain radiographs and CT scans were used to detect LSTV. Disc degeneration was analyzed at the L3-4, L4-5, and L5-S1 disc levels with magnetic resonance imaging. The difference in disc degeneration at each level by the presence of LSTV was also analyzed. The effect of lumbar curve type on the disc degeneration of each level was then determined. To minimize confounding factors, logistic regression analysis was performed. RESULTS: The overall prevalence of LSTV in patients with AIS confirmed by CT scans was 12.2% (47/385). The proportion of grade II or more disc degeneration at the L4-5 level was higher in the LSTV(+) group than in the LSTV(-) group (29.8% vs.19.2%) although it was not statistically significant (P = 0.093). Large lumbar curves showed a positive correlation with disc degeneration at the L5-S1 level (P = 0.022). CONCLUSION: The prevalence of LSTV in patients with AIS was 12.2%. A trend of early degeneration in L4-5 level discs was found in patients with AIS with LSTV although it was not statistically confirmed. Disc degeneration at the L5-S1 level is related to a large lumbar curve. If patients with AIS with large lumbar curves have LSTV, consideration should be given to stopping the distal fusion at L3 instead of L4. LEVEL OF EVIDENCE: 4.

The clinical importance of sacral slanting in patients with adolescent idiopathic scoliosis undergoing surgery.

BACKGROUND CONTEXT: The phenomenon of sacral slanting has not been assessed in patients with adolescent idiopathic scoliosis (AIS). It could be important in determining distal fusion level. PURPOSE: The purpose of this study is to clarify sacral slanting and to reveal frequency, character, and clinical importance of sacral slanting in AIS patients who underwent surgery. STUDY DESIGN/SETTING: Retrospective review of radiographs. PATIENT SAMPLE: The study included 389 patients who underwent surgery for AIS at a single center. OUTCOME MEASURES: Slanted angles of sacrum, distal curve types, and postoperative decompensation were assessed in whole spine anteroposterior radiographs. METHODS: This was a retrospective case series, which included 389 AIS patients who underwent corrective surgeries. The degree of sacral slanting was defined as the angle between the horizontal line and the upper end plate of the sacrum. Distal curves were classified according to the direction of L4 tilt (L4-left type and L4-right type). The frequency, direction, and relationship with curve types were analyzed descriptively. Postoperative changes of sacral slanting were compared by paired t test. Decompensation by distal fusion level and distal curve types was analyzed descriptively. The p value of less than .05 was considered as statistically significant. RESULTS: The frequency of sacral slanting was 19.5% (76 of 389), 29.6% (115 of 389), and 40.6% (158 of 389) by using criteria of 5°, 4°, and 3°, respectively. The 86.7% showed sacral slanting on the left side. The combination of L4-left type with left-sided sacral slanting was the most frequent (124 of 158, 78.7%). Slanted angles were decreased in some cases after surgery. Decompensation in the coronal plane was observed in 2 of 22 patients (9.1%) with a distal fusion level of L4 but in none of the 70 patients with a distal fusion level of L3. CONCLUSIONS: Sacral slanting in patients with AIS is a unique and frequently observed finding that has never been researched to date. Most importantly, sacral slanting is a critical consideration in selecting distal fusion level when planning corrective surgery in patients with AIS.

Does preoperative T1 slope affect radiological and functional outcomes after cervical laminoplasty?

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To analyze changes in the clinical and radiological factors related to cervical sagittal balance, relative to preoperative T1 slope, in patients with cervical myelopathy after laminoplasty (LP). SUMMARY OF BACKGROUND DATA: T1 slope is an important factor that should be considered before LP. However, until now, there have been no studies on how preoperative T1 slope affects the sagittal balance of cervical spine and various functional outcomes after LP. METHODS: Seventy-six patients with cervical myelopathy (M:F ratio = 50:26; mean age = 64.7 ± 9.1 yr) underwent a cervical LP and were followed for more than 2 years. Radiological measurements were performed to analyze the following parameters: (1) C2-C7 sagittal vertical axis; (2) T1 slope; (3) C2-C7 lordosis; and (4) thoracic kyphosis. The visual analogue scale, Japanese Orthopedic Association, neck disability index, and 36-Item Short-Form Health Survey were also investigated. Patients were divided into 2 groups according to preoperative T1 slope, with the cutoff value being the median preoperative T1 slope. Changes in clinical and radiological parameters were compared between the preoperative evaluation and final visit. RESULTS: Overall, C2-C7 sagittal vertical axis increased from 21.2 to 24.5 mm (P = 0.004) and C2-C7 lordosis decreased from 13.9° to 10.3° (P = 0.007) postoperatively. The T1 slope did not show any postoperative differences. Preoperative C2-C7 lordosis was larger in the high-T1 group (19.1°) than in the low-T1 group (9.0°). However, postoperative changes in C2-C7 sagittal vertical axis and C2-C7 lordosis did not show any between-group differences. Clinical outcomes (except neck pain) demonstrated overall improvement in both groups. Comparing changes in both groups showed no differences in neck pain, arm pain, neck disability index, or 36-Item Short-Form Health Survey physical component score between groups. CONCLUSION: Cervical sagittal balance is compromised after cervical LP. However, the degree of aggravation does not correlate with the preoperative T1 slope. Most clinical parameters demonstrate overall improvement regardless of preoperative T1 slope. LEVEL OF EVIDENCE: 3.