Computer-assisted virtual operation planning in anterior controllable anterior-displacement and fusion surgery for ossification of the posterior longitudinal ligament based on actual computed tomography data

The Reliability of Computer-Assisted Three-Dimensional Surgical Simulation of Posterior Osteotomies in Thoracolumbar Kyphosis Secondary to Ankylosing Spondylitis Patients

Objectives. The study was aimed at investigating the reliability of computer-assisted three-dimensional surgical simulation (CA3DSS) of posterior osteotomies in thoracolumbar kyphosis secondary to ankylosing spondylitis (TLKAS) patients. Methods. Eligible TLKAS patients who underwent posterior correction surgery with posterior osteotomies were consecutively included. Simulated posterior osteotomies were performed in Mimics and 3-Matic Medical software. Coronal and sagittal angle and alignment parameters were measured in preoperative full-length X-ray, preoperative original 3D spine (Pre-OS), simulated 3D spine (SS), and postoperative original 3D spine (Post-OS). Reliability was tested by both intraclass correlation coefficients (ICCs) and Bland-Altman analysis. Results. A total of 30 TLKAS patients were included. Excellent consistency of radiological parameters was shown between preoperative X-ray and Pre-OS model. In SS and Post-OS models, excellent reliabilities were shown in global kyphosis (ICC 0.832, 95% CI 0.677-0.916), thoracic kyphosis (ICC 0.773, 95% CI 0.577-0.885), and lumbar lordosis (ICC 0.896, 95% CI 0.794-0.949) and good reliabilities were exhibited in the main curve (ICC 0.680, 95% CI 0.428-0.834) and sagittal vertical axis (ICC 0.619, 95% CI 0.338-0.798). ICCs of correction angle achieved by pedicle subtraction osteotomy (PSO) was 0.754 (95% CI 0.487-0.892), and that of posterior column osteotomies (PCO) was 0.703 (95% CI 0.511-0.829). Bland-Altman analysis also showed good agreement for both Cobb angle and distance measurements in Pre-OS and SS models, and good reliabilities were shown in PCO and PSO in real spine and SS models. Conclusions. CA3DSS can provide an accurate measurement, and it is a reliable and effective method to conduct proper simulation for correction surgery with posterior osteotomies in TLKAS patients. This trial is registered with Chinese Clinical Trial Registry ChiCTR2100053808.

The feasibility and efficacy of computer-assisted screw inserting planning in the surgical treatment for severe spinal deformity: a prospective study

Background

The objective of the study was to explore the feasibility and efficacy of computer-assisted screw inserting planning (CASIP) in the surgical treatment for severe spinal deformity.

Methods

A total of 50 patients participated in this prospective cohort study. 25 patients were allocated into CASIP group and 25 patients were in Non-CASIP group. The demographic data, radiological spinal parameters were documented and analyzed. Each pedicle screw insertion was classified as satisfactory insertion or unsatisfactory insertion based on Gertzbein-Robbins classification. The primary outcome was the accuracy of pedicle screw placement. The secondary outcomes were the rate of puncturing screws, estimated blood loss, surgical time, correction rate and other radiological parameters.

Results

A total of 45 eligible patients completed the study. 20 patients were in CASIP group and 25 patients were in Non- CASIP group. The accuracy of pedicle screw placement in CASIP Group and Non-CASIP Group were (92.0 ± 5.5) % and (82.6 ± 8.3) % (P < 0.05), and the rate of puncturing screws were (0 (0–0)) % and (0 (0-6.25)) % (P < 0.05). The median surgical time were 280.0 (IQR: 260.0–300.0) min and 310 (IQR: 267.5–390.0) min in two group and showed significant statistic difference (P < 0.05).

Conclusions

CASIP has good feasibility and can gain a more accurate and reliable instruments fixation, with which spine surgeons can make a detailed and personalized screw planning preoperatively to achieve satisfying screw placement.

The clinical value of three-dimensional measurement in the diagnosis of thoracic myelopathy caused by ossification of the ligamentum flavum

Background

Thoracic ossification of the ligamentum flavum (OLF) is a major cause of thoracic myelopathy, which is often accompanied by multiple segmental stenosis or other degenerative spinal diseases. However, in the above situations, it is difficult to determine the exact segment responsible. The objective of this study was to analyze three-dimensional (3D) radiological parameters in order to establish a novel diagnostic method for discriminating the responsible segment in OLF-induced thoracic myelopathy, and to evaluate its superiority compared to the conventional diagnostic methods.

Methods

Eighty-one patients who underwent surgery for thoracic myelopathy caused by OLF from 2016 to 2020 were enrolled in this study as the myelopathy group, and 79 patients who had thoracic OLF but displayed no definite neurological signs from 2018 to 2020 were enrolled as the non-myelopathy group. We measured the one-dimensional (1D), two-dimensional (2D), and 3D radiological parameters, calculated their optimal cutoff values, and compared their diagnostic values.

Results

Significant differences were observed in the 1D, 2D, and 3D radiological parameters between the myelopathy and non-myelopathy groups (P<0.01). As a 3D radiological parameter, the OLF volume (OLFV) ratio (OLFV ratio = OLFV/normal canal volume × 100%) was the most accurate parameter for diagnosing OLF-induced thoracic myelopathy, with a diagnostic coincidence rate of 88.1%. We also found that an OLFV ratio of 26.3% could be used as the optimal cutoff value, with a sensitivity of 87.7% and a specificity of 88.6%. Moreover, the OLFV ratio [area under the curve (AUC): 0.92, 95% confidence interval (CI): 0.86-0.95] showed a statistically higher diagnostic value than the 1D and 2D parameters (AUC: 0.75, 95% CI: 0.67-0.81; AUC: 0.84, 95% CI: 0.77-0.89, respectively) (P<0.05). Pearson correlation analysis illustrated that the OLFV ratio was significantly negatively correlated with preoperative modified Japanese Orthopedic Association (mJOA) score (r=-0.73, 95% CI: -0.81 to -0.60, P<0.01).

Conclusions

Our results demonstrate the superiority of the OLFV ratio over the conventional 1D and 2D computed tomography (CT)-based radiological parameters for the diagnosis of OLF-induced thoracic myelopathy. The novel diagnostic method based on the OLFV ratio will help to determine the responsible segment in multi-segmental thoracic OLF or when thoracic OLF coexists with other degenerative spinal diseases. The OLFV ratio also accurately reflects the clinical state of symptomatic patients with thoracic OLF.

How much space of the spinal canal should be restored by hoisting the vertebrae-OPLL complex for sufficient decompression in anterior controllable antedisplacement and fusion? A multicenter clinical radiological study

BACKGROUND CONTEXT

Anterior controllable antedisplacement and fusion (ACAF) is a novel surgical technique for the treatment of ossification of the posterior longitudinal ligament (OPLL). Its prognostic factors for decompression have not been well studied. Additionally, no detailed radiological standard has been set for hoisting the vertebrae-OPLL complex (VOC) in ACAF.

PURPOSE

To identify the possible prognostic factors for decompression outcomes after ACAF for cervical OPLL, to determine the critical value of radiological parameters for predicting good outcomes, and to establish a radiological standard for hoisting the VOC in ACAF.

STUDY DESIGN

This was a retrospective multicenter study.

PATIENT SAMPLE

A total of 121 consecutive patients with OPLL who underwent ACAF at a point between January 2017 and June 2018 at any one of seven facilities and were monitored for at least 1 year afterward were enrolled in a multicenter study.

OUTCOME MEASURES

Japanese Orthopedic Association (JOA) scores, recovery rate (RR) of neurologic function, and surgical complications were used to determine the effectiveness of ACAF.

METHODS

Patients were divided into two groups according to their RR for neurologic function. Patients with an RR of ≥50% and an RR of <50% were designated as having good and poor decompression outcomes, respectively. The relationship between various possible prognostic factors and decompression outcomes was assessed by univariate and multivariate analysis. The receiver operating characteristic curve was used to determine the optimal cutoff value of the radiological parameters for prediction of good decompression outcomes. Next, the patients were redivided into three groups according to the cutoff value of the selected radiological parameter (postoperative anteroposterior canal diameter [APD] ratio). Patients with postoperative APD ratios of ≤80.7%, 80.7%-100%, and ≥100% were defined as members of the incomplete, optimal, and excessive antedisplacement groups, respectively. Differences in decompression outcomes among the three groups were compared to verify the reliability of the postoperative APD ratio and assess the necessity of excessive antedisplacement.

RESULTS

Multivariate logistic regression analysis showed that patients' age at surgery (odds ratio [OR]=1.18; 95% confidence interval [CI]=1.08-1.29; p<.01) and postoperative APD ratio (OR=0.83; 95% CI=0.77-0.90; p<.01) were independently associated with decompression outcomes. The optimal cutoff point of the postoperative APD ratio was calculated at 80.7%, with 86.2% sensitivity and 73.5% specificity. There were no significant differences in the postoperative JOA scores and RRs between the excessive antedisplacement group and optimal antedisplacement group (p>.05). However, a lower incidence of cerebrospinal fluid leakage and screw slippage was observed in the optimal antedisplacement group (p<.05).

CONCLUSIONS

Patients' age at surgery and their postoperative APD ratio are the two prognostic factors of decompression outcomes after ACAF. The postoperative APD ratio is also the most accurate radiological parameter for predicting good outcomes. Our findings suggest that it is essential for neurologic recovery to restore the spinal canal to more than 80.7% of its original size (postoperative APD ratio >80.7%), and restoration to less than its original size (postoperative APD ratio <100%) will help reduce the incidence of surgical complications. This may serve as a valuable reference for establishment of a radiological standard for hoisting the VOC in ACAF.

Anterior controllable antidisplacement and fusion surgery for the treatment of extensive cervico-thoracic ossification of posterior longitudinal ligament with severe myelopathy: case report and literature review

OPLL generally occurs in the cervical spine and involves no more than three vertebral segments, while extensive OPLL that involves the cervico-thoracic spine and spans over multiple segments is rare. Surgically it is difficult to achieve a satisfactory clinical outcome without surgical complications via the traditional anterior or posterior approaches. We report the first application of Anterior controllable antidisplacement and fusion (ACAF) in treating extensive cervico-thoracic OPLL. A 45-year old patient experienced severe walking disturbance, bladder and bowel dysfunction for 5 months after a fall. His preoperative Japanese Orthopedic Association (JOA) score was 8 of 17. Preoperative CT and MRI demonstrated a K-line (-) and mixed-type extensive OPLL from C2 to T2, causing significant cord compression. After ACAF surgery, neurological symptoms improved immediately without postoperative complications. Postoperative CT and MRI scanning showed restoration of spinal canal cross section and cord decompression. At 6 months he was able to stand and walk again without assistance and urinary bladder and bowel function returned to normal completely. At 15 months his JOA score was 14 of 17. ACAF surgery provides a promising alternative for the treatment of extensive cervico-thoracic OPLL.

Computer-Based 3D Simulations to Formulate Preoperative Planning of Bridge Crane Technique for Thoracic Ossification of the Ligamentum Flavum

Background

The bridge crane technique is a novel surgical technique for the treatment of thoracic ossification of the ligamentum flavum (TOLF), but its preoperative planning has not been studied well, which limits the safety and efficacy of surgery to some extent. The purpose of this study was to investigate the method of application and effect of computer-aided preoperative planning (CAPP) on the bridge crane technique for TOLF.

Material/Methods

This retrospective multi-center included 40 patients with TOLF who underwent the bridge crane technique from 2016 to 2018. According to the utilization of CAPP, patients were divided into Group A (with CAPP, n=21) and Group B (without CAPP, n=19). Comparisons of clinical and radiological outcomes were carried out between the 2 groups.

Results

The patients in Group A had higher post-mJOA scores and IR of neurological function than those in Group B (p<0.05). Group A had shorter surgery time, fewer fluoroscopic images, and lower incidence of complications than Group B. In Group A, there was a high consistency of all the anatomical parameters between preoperative simulation and postoperative CT (p>0.05). In Group B, there were significant differences in 3 anatomical parameters between postoperative simulation and postoperative CT (p<0.05). In Group B, the patients with no complications had higher post-SVOR and lower SVRR and height of posterior suspension of LOC in postoperative CT than those in postoperative simulation (p<0.05).

Conclusions

CAPP can enable surgeons to control the decompression effect accurately and reduce the risk of related complications, which improves the safety and efficacy of surgery.