What Are the Important Predictors of Postoperative Functional Recovery in Patients With Cervical OPLL? Results of a Multivariate Analysis

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The objective of this study was to identify important predictors of poor functional recovery in patients undergoing surgery for cervical ossification of the posterior longitudinal ligament (OPLL).

METHODS

This was a retrospective cohort study of 142 OPLL patients with laminoplasty; 135 had complete radiographical data and were followed up for ≥2 years. The following OPLL characteristics were compared between patients with "good" and "poor" outcomes (Japanese Orthopedic Association [JOA] recovery rate ≥50% and <50%, respectively): number of ossified levels, OPLL classification, ossification shape, K-line, canal-occupying ratio, and increased magnetic resonance imaging (MRI) signal intensity. Predictors of functional recovery were identified.

RESULTS

Pre- and postoperative (2 years following surgery) JOA scores were 10.6 ± 2.9 and 14.1 ± 2.2, respectively, indicating significant improvement following laminoplasty (P < .001). The average JOA recovery rate was 53.4% ± 34.7%, with 81 (60.0%) and 54 (40.0%) patients in the better and poorer neurological outcome groups, respectively. The canal occupation ratio of OPLL ≤60%/>60% were 117 (86.7%) and 18 (13.3%) patients, respectively. In the stepwise logistic regression analysis, an occupation ratio greater than 60% was identified as a significant factor for poor postoperative neurological outcome (relative risk, 4.82; 95% confidential interval, 1.61-14.46, P = .005).

CONCLUSIONS

This multivariate analysis demonstrated a large size OPLL (occupying ratio >60%) was associated with a risk of poor neurological recovery roughly 5 times greater, and therefore other types of surgery are recommended in cases with such a ratio.

Local Sagittal Alignment of the Lumbar Spine and Range of Motion in 627 Asymptomatic Subjects: Age-Related Changes and Sex-Based Differences

Study Design

Prospective cohort imaging study.

Purpose

This study aimed to evaluate lumbar sagittal alignment and range of motion (ROM) using radiographs in a large asymptomatic cohort and identify sex-based differences and age-related changes in the subjects.

Overview of Literature

Several researchers have tried to establish normal alignment and kinematic behavior of the lumbar spine, using plain radiographs. Few studies have employed a large and sex-and age-balanced cohort.

Methods

Total 627 healthy volunteers (at least 50 males and 50 females in each age decade, from the 3rd to the 8th decade) underwent whole spine radiography in the standing position; lumbar spine radiography was performed for all subjects in the recumbent position. Lumbar lordosis (LL, T12-S1) and ROM during flexion and extension were measured using a computer digitizer.

Results

The mean LL was 36.8°±13.2° in the recumbent position and 49.8°±11.2° in the standing position. The LL was greater in the standing position than in the recumbent position; further, LL was higher in females as compared to that in males. Local lordosis at each disk level increased incrementally with distal progression through the lumbar spine in both the positions. Local lordosis at L4- S1 was 29.8°±8.0° in the recumbent position and 34.2°±8.3° in the standing position and occupied 85.1% and 70.8% of the total LL, respectively. However, local lordosis in the standing position decreased with age at L2-3, L3-4, and L4-5 levels. Total lumbar ROM (T12-S1) decreased with age. The ROM in females was higher than that in males.

Conclusions

We established the standard value and age-related changes in the lumbar alignment and ROM in each age decade in asymptomatic subjects. These data will be useful and provide the normal values for comparison in clinical practice to identify sexbased differences and age-related changes.

Experimental and clinicopathological analysis of HOXB9 in gastric cancer

The association between homeobox (HOX)B9 expression and tumor malignancy was identified recently. It was reported that HOXB9 induced tumor angiogenesis, and associated with poor prognosis in patients with breast and colon cancer. On the other hand, regional lymph nodes are the most common site of tumor spread, and lymph node metastasis is a major prognostic factor in gastric cancer. It was hypothesized that HOXB9 promotes tumor lymphangiogenesis and induces tumor progression, invasion and metastasis in gastric cancer. The aim of the present study was to evaluate the correlation between HOXB9 expression, prognosis and clinicopathologic factors in patients with gastric cancer, and to assess the contribution of HOXB9 expression to tumor cell lymphangiogenesis in vitro. HOXB9 expression was evaluated by immunohistochemistry in resected tumor tissues from 58 patients with gastric cancer, and the association between prognosis and clinicopathologic factors was determined. HOXB9 gene was overexpressed in human gastric cancer TMK-1 cells and the effect of HOXB9 overexpression on the expression of vascular endothelial growth factor (VEGF)-C, VEGF-D and VEGF receptor (R)-3 was determined. It was demonstrated that the depth of tumor invasion, the number of node metastases, lymphatic invasion and vascular invasion were significantly associated with HOXB9 expression. Overall survival was decreased in patients with HOXB9 expression. The mRNA expression of VEGF-D but not of VEGF-C and VEGFR-3 was increased in HOXB9-overexpressing TMK-1 cells compared with control cells. In conclusion, HOXB9 expression was positively correlated with gastric cancer progression and lymphangiogenesis marker expression. HOXB9 may be associated with lymphogenic metastasis.

Evaluation of sagittal alignment and range of motion of the cervical spine using multi-detector- row computed tomography in asymptomatic subjects

To evaluate the sagittal alignment and range of motion (ROM) of the cervical spine during cervical flexion and extension ,using multi-detector-row-computed tomography (MDCT) in asymptomatic subjects.Understanding the normal alignment and range of motion of the cervical spine is very important while evaluating patients with cervical spine instability and abnormal alignment. Several reports using plain radiographic data have assessed the alignment and ROM of the cervical spine during flexion and extension. However, there has been no such report using MDCT. Ninety-eight subjects who did not have cervical spine-related symptoms were enrolled. After myelography, all subjects underwent cervical MDCT in cervical flexion and extension. Sagittal alignment and ROM between C2 and C7 were measured.The sagittal alignment between C2 and C7 was -11.7°±8.3° (mean ± standard deviation) in flexion and 26.5°± 12.9° in extension. The C5/6 level showed maximum kyphosis in flexion. The C6/C7 level demonstrated maximum lordosis in extension. ROM between C2 and C7 was 37.9°±11.2°. The C2/3 level showed the lowest ROM and the C5/C6 level showed the highest ROM among the intervertebral levels evaluated.The sagittal alignment and ROM of the cervical spine during flexion and extension in asymptomatic subjects were measured using MDCT. Each level between C2 and C7 could be evaluated in detail without any influence due to degenerative changes in the spine or soft tissues of the shoulder. MDCT generated a more precise understanding of the dynamic changes at each evaluated intervertebral level in the cervical spine.

Level of Evidence : Level II

Trends of postoperative length of stay in spine surgery over 10 years in Japan based on a prospective multicenter database

OBJECTIVES

To identify factors associated with prolonged length of stay (LOS) in spine surgery, with the goal of establishing details of LOS for multiple diseases and surgical procedures.

PATIENTS AND METHODS

The subjects were patients who underwent spine surgery at 10 facilities in the Nagoya Spine Group from January 2005 to December 2015. Data were collected for patient background, primary spinal pathology, anatomical location of the lesion, and surgical methods. The primary outcome was LOS, which was defined as the calendar days from surgery to hospital discharge.

RESULTS

A total of 10,829 patients (5953 males, 4876 females; age 5-93 years, mean 60.2 ± 28.8 years) were identified in the database. Average follow-up was 61 months (range: 13-120 months). Average LOS was 22.3 ± 21.3 days, and there was a gradual decrease in LOS over the study period. LOS was significantly correlated with age, and prolonged LOS was significantly associated with thoracic spine surgery and significantly longer after surgery with instrumentation. Average LOS was >30 days for intramedullary tumor resection and posterior cervical fusion, but only 10.2 days for microendoscopic discectomy. Reoperation was performed in 210 patients (1.9%) and these patients had a significantly higher average LOS of 43.1 days.

CONCLUSION

These results will assist quality improvement in spine surgery. The identified risk factors for prolonged LOS will also assist in planning of surgery, postoperative care, and discharge, with the goal of reducing health care costs.

MR T2 image classification in adult patients of cervical spinal cord injury without radiographic abnormality: A predictor of surgical outcome

OBJECTIVES

Although patients with cervical spinal cord injury without radiographic abnormality (SCIWORA) present increased signal intensity (ISI) on magnetic resonance imaging (MRI), its degree has not been examined. This study evaluated the clinical effectiveness of MRI-based ISI in adult patients of SCIWORA. Its predictive value for symptom severity was also evaluated.

PATIENTS AND METHODS

One-hundred consecutive SCIWORA patients who had undergone expansive laminoplasty were enrolled. Among them, 79 were male and 21 were female. The mean age was 55 years (range 20-87). All patients underwent MRI in the acute phase, and ISI was classified into three groups based on sagittal T2-weighted MRI: Grade 0, none; Grade 1, light (obscure); and Grade 2, intense (bright). The pre- and postoperative neurological status was evaluated using the Japanese Orthopaedic Association scoring system for cervical myelopathy (JOA score) and the ASIA impairment scale (AIS).

RESULTS

Preoperative MRI showed Grade 0 in 8 patients, Grade 1 in 49 patients, and Grade 2 in 43 patients. There were no differences in age and gender among three groups. The pre- and postoperative JOA scores decreased significantly with an increasing ISI grade. The recovery rate of JOA score decreased with the ISI grade. The ISI grade tended to increase with the pre- and postoperative AIS grades. ISI Grade 2 on MRI was observed in severely paralyzed cases.

CONCLUSIONS

MRI-based ISI classification is correlated with preoperative symptom severity in adult patients with SCIWORA and can be a predictor of surgical outcome.

Postoperative Complications Associated With Spine Surgery in Patients Older Than 90 Years: A Multicenter Retrospective Study

STUDY DESIGN

A review of a prospective database.

OBJECTIVES

Surgery for elderly patients is increasing yearly due to aging of society and the desire for higher quality of life. The goal of the study was to examine perioperative complications in spine surgery in such patients.

METHODS

A multicenter study of surgical details and perioperative complications was performed in 35 patients aged older than 90 years who underwent spinal surgery, based on a review of a prospective database. The frequency and severity of complications were assessed, and the effects of patient-specific and surgical factors were examined. Major complications were defined as those that were life threatening, required reoperation in the perioperative period or left a permanent injury. Ambulatory function before and after surgery was also analyzed.

RESULTS

Perioperative complications occurred in 19 of the 35 cases (54%), and included 11 cases of postoperative delirium, most of which occurred after cervical spine surgery. There were 8 major complications (23%), including cerebral infarction (n = 3), coronary heart disease (n = 3), pulmonary embolism (n = 1), and angina (n = 1). Preoperative motor deficit, operative time, estimated blood loss, and instrumented fusion were significantly associated with major complications. An improved postoperative ambulatory status occurred in 61% of cases, with no change in 33%, and worsening in 2 cases (6%).

CONCLUSIONS

Timing of surgery before paralysis progression and reduced surgical invasiveness are important considerations in treatment of the very elderly. Improved outcomes can be obtained with better management of spine surgery for patients aged 90 years or older.

Lateral thermal spread and recurrent laryngeal nerve paralysis after minimally invasive esophagectomy in bipolar vessel sealing and ultrasonic energy devices: a comparative study

BACKGROUND

This study aimed to compare the extent of lateral thermal spread of surrounding tissues after the use of advanced bipolar and ultrasonic coagulation and shearing devices. Association between recurrent laryngeal nerve paralysis (RLNP) and such devices was assessed in patients who underwent minimally invasive esophagectomy (MIE).

METHODS

LigaSure^™ (LS) and Sonicision^™ (SONIC) were used. In ex vivo experiments using the porcine muscle, blade temperature and tissue temperature were measured using a thermometer after the activation of both devices. For the clinical assessment, 46 consecutive patients who received MIE were retrospectively assessed.

RESULTS

The temperature generated at the blade of both devices increased with the activation time. The blade temperature of LS was significantly lower than that of SONIC (P < 0.001). The blade temperature of SONIC exceeded 100 °C after 3-s activation. The temperature of surrounding tissues after a single activation of the devices decreased with the tissue distance from activation blade. The temperatures of tissues at 1 and 2 mm away from the blade side of LS were significantly lower than those of SONIC (P = 0.001 and P < 0.001, respectively). The temperature of tissue 2 mm away from the blade side of LS increased 6.4 °C from the baseline temperature. Furthermore, the incidence of RLNP in the LS group was lower than that in the SONIC group (P = 0.044).

CONCLUSION

This study highlights the necessity of spatial and temporal recognition of the thermal spread of coagulation and shearing devices to reduce the thermal injuries following MIE.

Surgical outcomes of spinal cord and cauda equina ependymoma: Postoperative motor status and recurrence for each WHO grade in a multicenter study

BACKGROUND

The goals of the study are to analyze postoperative outcomes and recurrence in cases of spinal cord and cauda equina ependymoma in each World Health Organization (WHO) Grade, and to examine the influence of extent of surgical removal on prognosis. Spinal ependymoma has a relatively high frequency among intramedullary spinal cord tumors. The tumor is classified in WHO guidelines as grades I, II, and III, but few studies have examined postoperative prognosis based on these grades.

METHODS

The records of 80 patients undergoing surgery for spinal cord and cauda equina ependymoma were examined in a multicenter study using a retrospective database. Neurological motor status, pathological type, extent of resection, and tumor recurrence were evaluated.

RESULTS

The histopathological types were grade I in 23 cases (myxopapillary: 21, subependymoma: 2), grade II in 52 cases, and grade III in 5 cases (including all anaplastic cases). Total resection was performed in 60 cases (83%), and eight cases had recurrence, including 2 in WHO grade I, 2 in grade II, and 4 in grade III. The 5-year recurrence-free survival rates were 90%, 91%, and 20% in grades I, II and III, respectively. Adjuvant radiotherapy for the local site was performed in 8 cases, including 3 in grade I and 5 in grade III; however, 4 of the 5 grade III cases (80%) had recurrence after radiotherapy. Among 59 patients with normal ambulation or independence without external assistance (McCormick Grade I or II), 53 (90%) maintained the same mobility after surgery. In cases that underwent total resection, the recurrence rate was significantly lower (p < 0.01). A good preoperative motor status also resulted in significantly better postoperative recovery of motor status (p < 0.05).

CONCLUSIONS

Total resection of spinal cord and cauda equina ependymoma leads to postoperative motor recovery and may reduce tumor recurrence. Therefore, early surgery for this tumor is recommended before aggravation of paralysis.

Long-term outcome after resection for recurrent oesophageal cancer

Background

The efficacy of surgical resection for lymph node (LN) or distant recurrence of oesophageal cancer has not been sufficiently investigated. The objective of this study was to reveal appropriate indications for a surgical approach.

Methods

A total of 42 patients who underwent resection for recurrent or residual oesophageal squamous cell carcinoma after surgery or definitive chemoradiotherapy (dCRT) between April 2004 and August 2016 were identified. These resections did not include salvage oesophagectomy. The long-term outcomes of these patients were retrospectively analysed.

Results

Thirty-three patients underwent LN resection, 6 patients underwent lung resection, and 3 patients underwent resection for other recurrent tumours. The 5-year overall survival (OS) of patients who underwent salvage abdominal lymphadenectomy after dCRT was significantly better than that of patients who underwent salvage cervical or mediastinal lymphadenectomy (46.9% vs. 0.0%, P=0.006). The 5-year OS of patients who underwent salvage resection for LNs outside the radiation field was significantly better than that of patients who underwent resection inside the radiation field (47.6% vs. 8.9%, P=0.027). The 5-year OS of patients who underwent salvage resection for recurrent LNs was significantly better than that of patients who underwent salvage resection for residual LNs (21.7% vs. 0.0%, P<0.001). Among the 42 patients, 9 survived more than 3 years: 4 after salvage abdominal lymphadenectomy, 3 after resection for solitary lung recurrence, and 2 others.

Conclusions

The use of the appropriate surgical approach might improve the prognosis of patients with abdominal LN recurrence, LN recurrence outside the radiation field, or a solitary lung recurrence of oesophageal cancer.

Clinical significance of esophageal invasion length for the prediction of mediastinal lymph node metastasis in Siewert type II adenocarcinoma: A retrospective single-institution study

AIM

This study investigated whether esophageal invasion length (EIL) of a tumor from the esophagogastric junction could be a possible indicator of mediastinal lymph node metastasis and survival in patients with Siewert type II adenocarcinoma.

METHODS

One hundred and sixty-eight patients with Siewert type II tumor who underwent surgery were enrolled. Metastatic stations and recurrent lymph node sites were classified into cervical, upper/middle/lower mediastinal, and abdominal zones. EIL was correlated with overall metastasis or recurrence in individual zones and with survival.

RESULTS

Siewert type II patients with an EIL of more than 25 mm (>25 mm EIL group) had a higher incidence of overall metastasis or recurrence in the upper and middle mediastinal zones than those with an EIL of less than or equal to 25 mm (≤25 mm EIL group) (P = .001 and P < .001). Disease-free and overall survival in the >25 mm EIL group were significantly lower than those of the ≤25 mm EIL group (P < .001). None of the Siewert type II patients with metastasis or recurrence in the upper and middle mediastinal zones survived for more than 5 years. Only an EIL of more than 25 mm was a significant preoperative predictor of overall metastasis or recurrence in the upper and middle mediastinal zones (odds ratio, 8.85; 95% CI, 2.31-33.3; P = .001).

CONCLUSION

A multimodal-therapeutic strategy should be investigated in Siewert type II patients once the tumor has invaded more than 25 mm to the esophageal wall.

A retrospective imaging study of surgical outcomes and range of motion in patients with cervical ossification of the posterior longitudinal ligament

PURPOSE

The K line was introduced in a previous study, but did not include the cervical range of motion (ROM) as a parameter for evaluating surgical outcomes for patients with cervical ossification of the posterior longitudinal ligament (OPLL), and few reports have used both the K line and X-ray evaluations of the cervical ROM to describe the surgical outcomes in such patients.

METHODS

Double-door C2-C7 or C3-C7 laminoplasty was performed in 100 patients with cervical OPLL who were classified according to the K line [86 patients, K line (+) and 14 patients, K line (-)]. Preoperative and 1-year postoperative Japanese Orthopedic Association (JOA) scores were used to evaluate recovery rates. Preoperative and postoperative C2-C7 lordotic angles were measured using the Cobb method. In addition, preoperative and postoperative sagittal alignments in flexion and extension were studied, and the flexion values were calculated by subtracting the preoperative and postoperative flexion ROM from extension ROM.

RESULTS

The mean JOA scores recovery rate were 57.3% in the K line (+) and 37.7% in the K line (-) groups (p < 0.05), and the respective corresponding mean postoperative C2-C7 lordotic angles were 9.1° and -3.4° (p < 0.001). In the K line (+) group, the JOA score recovery rate for a postoperative flexion value >0 was significantly lower than that for a postoperative flexion value ≤0 (p < 0.01), and the mean JOA score recovery rate worsened with an increased signal intensity on 1-year postoperative magnetic resonance imaging.

CONCLUSIONS

K line (+) patients exhibited sufficient neurological improvement after laminoplasty. However, even patients in this group had a low JOA score recovery rate if the postoperative flexion value was >0 and the 1-year postoperative increased signal intensity grade was 2 or 3.

Normative data for parameters of sagittal spinal alignment in healthy subjects: an analysis of gender specific differences and changes with aging in 626 asymptomatic individuals

PURPOSE

This study aims to establish normative data for parameters of spino-pelvic and spinal sagittal alignment, gender related differences and age-related changes in asymptomatic subjects.

METHODS

A total of 626 asymptomatic volunteers from Japanese population were enrolled in this study, including 50 subjects at least for each gender and each decade from 3rd to 8th. Full length, free-standing spine radiographs were obtained. Cervical lordosis (CL; C3-7), thoracic kyphosis (TK; T1-12), lumbar lordosis (LL; T12-S1), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and sagittal vertical axis (SVA) were measured.

RESULTS

The average values (degrees) are 4.1 ± 11.7 for CL, 36.0 ± 10.1 for TK, 49.7 ± 11.2 for LL, 53.7 ± 10.9 for PI, 14.5 ± 8.4 for PT, and 39.4 ± 8.0 for SS. Mean SVA is 3.1 ± 12.6 mm. Advancing age caused an increase in CL, PT and SVA, and a decrease in LL and SS. There was a significant gender difference in CL, TK, LL, PI, PT and SVA. From 7th decade to 8th decade, remarkable decrease of LL & TK and increase of PT were seen. A large increase of SVA was also seen between 60' and 70'.

CONCLUSION

Standard values of spino-pelvic sagittal alignment were established in each gender and each decade from 20' to 70'. A remarkable change of spino-pelvic sagittal alignment was seen from 7th decade to 8th decade in asymptomatic subjects.

Comparative Study of Untethering and Spine-Shortening Surgery for Tethered Cord Syndrome in Adults

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

Although untethering surgery has been a standard treatment in patients with adult tethered cord syndrome (TCS), spine-shortening osteotomy (SSO) has recently been performed as an alternative technique. The purpose of this study was to compare the clinical outcomes of the two procedures for TCS in adults.

METHODS

Fourteen patients (37.7 ± 12.5 years) with TCS were enrolled at 6 hospitals. Their clinical charts, operative records, and follow-up data were reviewed. The categories of tethering lesions were tight terminal filum in 1 patient, lipoma in 5 patients, and lipomyelomeningocele in 8 patients. Eleven patients underwent untethering surgery, and 3 patients underwent SSO surgery.

RESULTS

There were no significant differences in age, sex, types of preoperative symptoms, or duration of follow-up between the two groups. The preoperative duration of symptoms was significantly longer (25 ± 12.4 years) and the percentage of those with prior surgery was higher in the SSO group (66.7%). The preoperative pathology was lipomeningocele in all SSO group and lipoma or tight terminal filum in the untethering group. Cerebrospinal fluid leakage and urinary infection occurred in 1 patient each among those with untethering, and massive intraoperative bleeding occurred in 1 patient with SSO. SSO provided better clinical improvement than untethering surgery (p = 0.003).

CONCLUSIONS

Based on this small retrospective case series, SSO appears to provide clinical improvement at least comparable to the untethering procedure, especially in more challenging cases.

Intrathecal morphine for postoperative pain control after laminoplasty in patients with cervical spondylotic myelopathy

OBJECTIVES

To examine the clinical efficacy of intrathecal morphine as postoperative analgesia for cervical laminoplasty.

SUMMARY OF BACKGROUND DATA

Patients who undergo posterior cervical spinal surgery frequently experience significant postoperative pain. Postoperative pain contributes to patient morbidity because of decreasing early voluntary mobilization and delayed rehabilitation. Intrathecal morphine is known to be a simple and effective analgesia. However, the effectiveness of intrathecal morphine for cervical spinal surgery has not yet been reported.

METHODS

Seventy-eight patients with cervical spondylotic myelopathy were divided into two groups prospectively, a diclofenac suppository (DS) group who received 50 mg diclofenac suppository at the end of the surgery, and an intrathecal morphine (ITM) group who were preoperatively administered 0.3 mg of morphine chloride, intrathecally, via a lumbar puncture. All patients underwent double-door laminoplasty of C3-6 or C3-7 level. Visual analog scale (VAS) of cervical pain, self-rating pain impression, supplemental analgesic usage, and complication rate were evaluated until the seventh postoperative day.

RESULTS

Thirty-one patients in the DS group and 32 patients in the ITM group were finally assessed. No baseline variable differences between the two groups were observed. The VAS was significantly lower in the ITM group at 4 h and 24 h until the seventh postoperative day. Self-rating pain impression was significantly better in the ITM group. No significant difference was observed in complication rate.

CONCLUSIONS

Intrathecal morphine was an effective and safe analgesic method for cervical laminoplasty in patients with cervical spondylotic myelopathy.

Narrow cervical canal in 1211 asymptomatic healthy subjects: the relationship with spinal cord compression on MRI

PURPOSE

Narrow cervical canal (NCC) has been a suspected risk factor for later development of cervical myelopathy. However, few studies have evaluated the prevalence in asymptomatic subjects. The purpose of this study was to investigate the prevalence of NCC in a large cohort of asymptomatic volunteers.

METHODS

This study was a cross-sectional study of 1211 asymptomatic volunteers. Approximately 100 men and 100 women representing each decade of life from the 20s to the 70s were included in this study. Cervical canal anteroposterior diameters at C5 midvertebral level on X-rays, and the prevalence of spinal cord compression (SCC) and increased signal intensity (ISI) changes on MRI were evaluated. Receiver operating characteristic analysis was performed to determine the cut-off value of the severity of canal stenosis resulting in SCC.

RESULTS

NCC (<14 mm) was observed in 123 (10.2 %) subjects. SCC and ISI were found in 64 (5.3 %) and 28 (2.3 %) subjects, respectively. The prevalence of NCC was significantly higher in females and older subjects, but the occurrence of severe NCC (<12 mm) did not increase with age. The canal size in subjects with SCC or ISI was significantly smaller than in those without SCC (p < 0.0001). The cut-off values of cervical canal stenosis resulting in SCC were 14.8 and 13.9 mm in males and females, respectively.

CONCLUSIONS

The prevalence of NCC was considerably lower among asymptomatic healthy volunteers; the cervical canal diameter in subjects with SCC or ISI was significantly smaller than in asymptomatic subjects; NCC is a risk factor for SCC.

The influence of venous thromboembolism on prognosis of esophageal cancer patients

29

Background: Venous thromboembolism (VTE) is sometimes found in esophageal cancer patients who underwent surgical treatment. VTE contains deep vein thrombosis, pulmonary embolism and catheter-related thrombosis. Our previous study revealed that pre-therapeutic plasma fibrinogen level, C-reactive protein level, adenocarcinoma histology and neck lymph node dissection are the risk factors for venous thromboembolism in patients[Surg Today, 2015]. However, the correlation between VTE and prognosis is not clear in esophageal cancer. We hypothesized that VTE may have an impact on prognosis of esophageal cancer patients. Methods: One hundred and seventy-two patients who underwent radical esophagectomy from March 2008 to December 2012 in our hospital were reviewed in this study. The existence of VTE was assessed from the neck to the pelvis with computed tomography at the initial visit and after neo-adjuvant chemotherapy (NAC) and 6thpostoperative day. The patient and tumor characteristics, neo-adjuvant chemotherapy were compared between patients with VTE (VTE group) and those without VTE (non-VTE group). The primary outcome is disease-free survival (DFS) and the secondary outcome is overall survival (OS). Results: Twenty-one VTE events among 172 patients (12%) were observed. Six of which occurred preoperatively and were considered to be associated with NAC, 14 were detected postoperatively and one occurred just after inserting a peripherally inserted central catheter preoperatively. The VTE group and the non-VTE group have homogenous characteristics in patients’ backgrounds and tumor features. We found no significant difference in median DFS and OS between two groups. However, in patients with pathologically N 0 or 1(7thedition of UICC TNM classification, n = 157), the median DFS was significantly shorter in VTE group compared with non-VTE group (41 months versus 64 months, p = 0.04). The recurrence risk increased 50.9% in VTE group in comparison with non VTE group (p = 0.048). By using logistic regression analysis, we found that existence of VTE is an independent risk factor with Odd’s ratio 2.964 (p = 0.026). Conclusions: Our study suggests that VTE may be the risk factor for recurrence in esophageal cancer patients.

Dynamic changes in the cross-sectional area of the dural sac and spinal cord in the thoracic spine

PURPOSE

The thoracic spine is considered a rigid region because it is restricted by the rib cage. Previously, we reported functional alignments and range of motion (ROM) at all segmental levels. The purpose of this study was to investigate dynamic changes of the dural sac and spinal cord in the thoracic spine using a multidetector-row computed tomography (MDCT).

METHODS

Fifty patients with cervical or lumbar spinal disease were prospectively enrolled. After preoperative myelography, MDCT was performed at maximum passive flexion and extension. The anteroposterior diameter and cross-sectional area of the dural sac and spinal cord in the axial plane were measured using Scion imaging software. We also evaluated the correlation between the change ratio of the cross-sectional area and segmental kyphotic angle and ROM.

RESULTS

In flexion, the anteroposterior diameter of the dural sac was larger than in extension. The cross-sectional area in the upper and middle regions was smaller, but was larger in the lower region. The anteroposterior diameter and cross-sectional area of the spinal cord in the upper and middle regions were smaller than in extension, but these values were nearly the same in both flexion and extension in the lower region. Change ratios of the cross-sectional area were correlated with segmental kyphotic angle rather than ROM.

CONCLUSIONS

The thoracic spine showed some dynamic changes of the dural sac and spinal cord in the axial plane within functional motion. Segmental kyphotic angle, rather than segmental ROM, was the more important factor affecting dimensions of the dural sac and spinal cord.

Feasibility of non-exposed endoscopic wall-inversion surgery with sentinel node basin dissection as a new surgical method for early gastric cancer: a porcine survival study

Non-exposed endoscopic wall-inversion surgery (NEWS) has been developed as an endoscopic full-thickness resection technique without translumenal communication to avoid intraabdominal infection or tumor seeding. We aimed to investigate the feasibility and safety of NEWS with sentinel node basin dissection (SNBD), which can minimize the area of lymphadenectomy for early gastric cancer (EGC), in 10 porcine survival models. After placing laparoscopic ports and making markings on both the mucosal and serosal sides of a simulated lesion, indocyanine green fluid was endoscopically injected into the submucosa at 4 quadrants around the lesion. An SN basin including the stained SNs was dissected, and a circumferential sero-muscular incision around the lesion and sero-muscular suturing were performed laparoscopically, with the lesion inverted toward the inside of the stomach. Finally, circumferential mucosal incision and transoral retrieval were made endoscopically. In all cases, the lesion was resected in an en bloc fashion, and all pigs survived without adverse events. After 1 week of observation, pigs were sacrificed for macroscopic investigation. The average procedural duration was 170 min (range 130-253 min). Intraoperative perforation occurred in 1 case, which could be safely treated by laparoscopic suturing. The number of dissected SN basins was 1 in 9 cases and 2 in 1 case. Necropsy revealed no signs of severe complication. This animal survival study demonstrated that NEWS with SNBD was safe and feasible. It may provide patients with possibly node-positive EGC a minimally-sized local resection and minimally-ranged lymphadenectomy without the risk of tumor dissemination.

Dynamic changes in the spinal cord cross-sectional area in patients with myelopathy due to cervical ossification of posterior longitudinal ligament

BACKGROUND CONTEXT

Dynamic changes in the spinal cord cross-sectional area due to cervical ossification of the posterior longitudinal ligament (C-OPLL) are unknown, but dynamic multidetector-row computed tomography (MDCT) may be a useful tool.

PURPOSE

The purpose of this study was to evaluate the influence of dynamic factors on the spinal cord in patients with C-OPLL using MDCT during flexion and extension after myelography.

STUDY DESIGN/SETTING

This was a prospective cohort study.

PATIENT SAMPLE

Participants included 107 prospectively enrolled consecutive patients with C-OPLL and myelopathy.

OUTCOME MEASURE

The outcome measure was the extension/flexion ratio at the spinal cord cross-sectional area at the most stenotic cervical level (SCASL).

METHODS

Dynamic MDCT was performed, and the SCASL was measured. Patients were divided into the kyphosis group or lordosis group according to C2-C7 alignment. They were divided further into the K-line (-) group or K-line (+) group. The Japanese Orthopedic Association (JOA) score was used to determine myelopathy severity.

RESULTS

All patients with C-OPLL had myelopathy, with a mean JOA score of 10.7 and mean disease duration of 16.7 months. The average extension/flexion ratio at all disc levels was less than 100%, suggesting that the spinal cord was compressed more during extension. In the kyphosis group, the spinal cord was compressed slightly more during flexion than during extension. In the K-line (-) group, the spinal cord was compressed more during flexion, although C2-C7 alignment was slightly lordotic on average. Large changes in the spinal cord cross-sectional area during extension-flexion and disease duration significantly influenced the severity of myelopathy.

CONCLUSIONS

Dynamic MDCT was useful for evaluating dynamic changes in the spinal cord. At the most stenotic level, the spinal cord became narrower during extension at all disc levels. In the kyphosis group and K-line (-) group, it became narrower during flexion. Cervical flexion may induce greater spinal cord compression in patients with kyphosis and K-line (-).

Essential Surgical Technique for French-Door (Double-Door) Laminoplasty

Introduction

We describe the surgical technique and the pitfalls of French-door laminoplasty.

Step 1: Patient Positioning

Position the patient to keep the cervical spine “parallel to the floor” or in the “reverse Trendelenburg position” with only a slight incline and place intraoperative neurological monitors to prevent intraoperative neurological deterioration.

Step 2: Surgical Approach

Use the common cervical posterior approach to expose the lamina and ligamentum flavum.

Step 3: Create Grooves

Cut the center of each lamina and create bilateral grooves using a high-speed burr.

Step 4: Open the Lamina

Open the lamina bilaterally and create a small hole in each one using a high-speed burr.

Step 5: Create Bone Struts

Create bone struts from the spinous processes and tie them to each lamina.

Step 6: Wound Closure

Perform meticulous closure of the wound to avoid wound-healing complications.

Results

In our original study¹², we treated forty-six patients with French-door laminoplasty and compared the surgical results of this procedure with those of open-door laminoplasty in a prospective, randomized controlled manner.

Indications

Contraindications

Pitfalls & Challenges

Surgical outcomes of modified lumbar spinous process-splitting laminectomy for lumbar spinal stenosis

The lumbar spinous process-splitting laminectomy (LSPSL) procedure was developed as an alternative to lumbar laminectomy. In the LSPSL procedure, the spinous process is evenly split longitudinally and then divided at its base from the posterior arch, leaving the bilateral paravertebral muscle attached to the lateral aspects. This procedure allows for better exposure of intraspinal nerve tissues, comparable to that achieved by conventional laminectomy while minimizing damage to posterior supporting structures. In this study, the authors make some modifications to the original LSPSL procedure (modified LSPSL), in which laminoplasty is performed instead of laminectomy. The purpose of this study was to compare postoperative outcomes in modified LSPSL with those in conventional laminectomy (CL) and to evaluate bone unions between the split spinous process and residual laminae following modified LSPSL. Forty-seven patients with lumbar spinal stenosis were enrolled in this study. Twenty-six patients underwent modified LSPSL and 21 patients underwent CL. Intraoperative blood loss and surgical duration were evaluated. The Japanese Orthopaedic Association (JOA) scale scores were used to assess parameters before surgery and 12 months after surgery. The recovery rates were also evaluated. Postoperative paravertebral muscle atrophy was assessed using MRI. Bone union rates between the split spinous process and residual laminae were also examined. The mean surgical time and intraoperative blood loss were 25.7 minutes and 42.4 ml per 1 level in modified LSPSL, respectively, and 22.7 minutes and 29.5 ml in CL, respectively. The recovery rate of the JOA score was 64.2% in modified LSPSL and 68.7% in CL. The degree of paravertebral muscle atrophy was 7.8% in modified LSPSL and 22.2% in CL at 12 months after surgery (p < 0.05). The fusion rates of the spinous process with the arcus vertebrae at 6 and 12 months in modified LSPSL were 56.3% and 81.3%, respectively. The modified LSPSL procedure was less invasive to the paravertebral muscles and could be a laminoplasty; therefore, the modified LSPSL procedure presents an effective alternative to lumbar laminectomy.