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Ito S, Nakashima H, Segi N, Ouchida J, Oishi R, Yamauchi I, Miyairi Y, Morita Y, Ode Y, Imagama S. Ten-Year Follow-up of Posterior Decompression and Fusion Surgery for Thoracic Ossification of the Posterior Longitudinal Ligament. J Bone Joint Surg Am 2024; 106:1600-1609. [PMID: 39102467 DOI: 10.2106/jbjs.23.01475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
BACKGROUND We evaluated the clinical, functional, and quality of life (QoL) outcomes of surgical treatment of thoracic ossification of the posterior longitudinal ligament (T-OPLL). METHODS We retrospectively evaluated 51 patients followed for ≥10 years after posterior decompression and corrective fusion surgery for T-OPLL. The data collected included demographics, comorbidities, and pre- and postoperative symptoms. The Japanese Orthopaedic Association (JOA) score, numerical rating scale (NRS) for back and leg pain, and EuroQol-5 Dimension-5 Level (EQ-5D-5L) were used to assess neurological function, pain, and QoL. Imaging evaluations were conducted to assess changes in kyphotic angles and ossification progression. RESULTS A significant improvement was observed in the JOA score from preoperatively (3.7) to 2 years postoperatively (7.9) (p < 0.05); the score remained stable thereafter. The mean EQ-5D-5L score improved from 0.53 preoperatively to 0.68 at 10 years postoperatively (p < 0.001). NRS scores for back and leg pain decreased from 5.4 to 3.5 and 4.0 to 3.0, respectively, from preoperatively to 10 years (p < 0.001 for both). Radiographic outcomes showed changes in kyphotic angles and ossification areas, with no significant progression after 2 years. Fourteen (27.5%) of the patients experienced postoperative complications. Of these, 8 (15.7%) required reoperation, 6 (11.8%) in the perioperative period and 2 (3.9%) later. Four (7.8%) of the patients underwent additional surgeries for conditions including lumbar spinal canal stenosis and cervical OPLL. Nonetheless, physical function in all cases with postoperative complications or additional surgery remained stable over the decade. CONCLUSIONS Surgical treatment of T-OPLL is effective in improving neurological function, QoL, and pain management over an extended period. The long-term outcomes of T-OPLL surgery revealed that, although cervical and lumbar spinal lesions led to reoperations, they did not affect QoL, and relative improvement was maintained even after 10 years. LEVEL OF EVIDENCE Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sadayuki Ito
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Ito Y, Ohtomo N, Nakamoto H, Kato S, Taniguchi Y, Kodama H, Sato Y, Kawamura N, Tonosu J, Higashikawa A, Saiki F, Takeshita Y, Anno M, Fukushima M, Iizuka M, Baba S, Ono T, Tachibana N, Hara N, Okamoto N, Azuma S, Sakamoto R, Iwai H, Oshina M, Sugita S, Hirai S, Yamato Y, Masuda K, Tanaka S, Oshima Y. Patient-Reported Outcomes and Patient Satisfaction Following Surgery for Thoracic Myelopathy. Spine Surg Relat Res 2024; 8:409-414. [PMID: 39131416 PMCID: PMC11310529 DOI: 10.22603/ssrr.2023-0279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/26/2023] [Indexed: 08/13/2024] Open
Abstract
Introduction The association between postoperative patient-reported outcomes (PROs) and patient satisfaction remains poorly defined in patients undergoing surgery for thoracic myelopathy. This study aimed to investigate PROs and patient satisfaction following surgical intervention for thoracic myelopathy. Methods A prospective cohort of 133 patients who underwent surgery for thoracic myelopathy at 13 hospitals between April 2017 and August 2021 was enrolled. Patient demographics and perioperative complications were recorded. PROs were assessed using questionnaires administered preoperatively and 1 year postoperatively, including the EuroQol-5 dimension, physical and mental component summaries of the 12-item Short-Form Health Survey, Oswestry Disability Index, and numerical rating scales for low back, lower extremity, and plantar pain. Patients were categorized into two groups: satisfied (very satisfied, satisfied, and slightly satisfied) and dissatisfied (neither satisfied nor dissatisfied, slightly dissatisfied, dissatisfied, and very dissatisfied). Results The mean age of the patients was 66.5 years, comprising 87 men and 46 women. The most common diagnoses were ossification of the ligamentum flavum (48.8%) and thoracic spondylotic myelopathy (26.3%). Seventy-four (55.6%) and 59 (44.3%) patients underwent decompression surgery and underwent decompression with fusion, respectively. Eight patients required reoperation due to postoperative surgical site infection, hematoma, and insufficient decompression in four, three, and one patient. Ninety (67.7%) patients completed both the preoperative and postoperative PRO questionnaires, all of which demonstrated significant improvement. Among them, 58 (64.4%) and 32 (35.6%) reported satisfaction and dissatisfaction with their treatment, respectively. The satisfied group showed superior improvement in PROs than the dissatisfied group, although there were no significant differences in complication rates between the two groups. Conclusions The 64.4% satisfaction rate observed in patients undergoing surgery for thoracic myelopathy was lower than that reported in previous studies on cervical or lumbar spine surgery. The dissatisfied group exhibited significantly poorer quality of life (QOL) and higher pain scores than the satisfied group.
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Affiliation(s)
- Yusuke Ito
- Department of Orthopaedic Surgery, University of Tokyo, Tokyo, Japan
| | - Nozomu Ohtomo
- Department of Orthopaedic Surgery, University of Tokyo, Tokyo, Japan
| | - Hideki Nakamoto
- Department of Orthopaedic Surgery, University of Tokyo, Tokyo, Japan
| | - So Kato
- Department of Orthopaedic Surgery, University of Tokyo, Tokyo, Japan
| | - Yuki Taniguchi
- Department of Orthopaedic Surgery, University of Tokyo, Tokyo, Japan
| | - Hiroyasu Kodama
- Department of Spine and Orthopedic Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Yusuke Sato
- Department of Spine and Orthopedic Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Naohiro Kawamura
- Department of Spine and Orthopedic Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Juichi Tonosu
- Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan
| | - Akiro Higashikawa
- Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety Kanto Rosai Hospital, Kanagawa, Japan
| | - Fumiko Saiki
- Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety Yokohama Rosai Hospital, Kanagawa, Japan
| | - Yujiro Takeshita
- Department of Orthopaedic Surgery, Japan Organization of Occupational Health and Safety Yokohama Rosai Hospital, Kanagawa, Japan
| | - Masato Anno
- Spine Center, Toranomon Hospital, Tokyo, Japan
| | | | - Masaaki Iizuka
- Department of Spinal Surgery, Japan Community Health-Care Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Satoshi Baba
- Department of Spinal Surgery, Japan Community Health-Care Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Takashi Ono
- Department of Spinal Surgery, Japan Community Health-Care Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Naohiro Tachibana
- Department of Orthopaedic Surgery, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Nobuhiro Hara
- Department of Orthopaedic Surgery, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Naoki Okamoto
- Department of Orthopaedic Surgery, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Seiichi Azuma
- Department of Orthopaedic Surgery, Japanese Red Cross Saitama Hospital, Saitama, Japan
| | - Ryuji Sakamoto
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, Tokyo, Japan
| | - Hiroki Iwai
- Department of Orthopaedic Surgery, Inanami Spine and Joint Hospital, Tokyo, Japan
| | - Masahito Oshina
- Department of Orthopaedic Surgery, NTT Medical Center Tokyo, Tokyo, Japan
| | - Shurei Sugita
- Department of Orthopaedic Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Shima Hirai
- Department of Orthopaedic Surgery, NHO Sagamihara National Hospital, Kanagawa, Japan
| | - Yukimasa Yamato
- Department of Orthopaedic Surgery, NHO Sagamihara National Hospital, Kanagawa, Japan
| | - Kazuhiro Masuda
- Department of Orthopaedic Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, University of Tokyo, Tokyo, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, University of Tokyo, Tokyo, Japan
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Morishita S, Yoshii T, Inose H, Hirai T, Yamada K, Matsukura Y, Egawa S, Hashimoto J, Takahashi T, Ogawa T, Fushimi K. Perioperative complications and cost of posterior decompression with fusion in thoracic spine for ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum -a comparative study using a national inpatient database. BMC Musculoskelet Disord 2024; 25:513. [PMID: 38961370 PMCID: PMC11221184 DOI: 10.1186/s12891-024-07617-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 06/21/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Although posterior decompression with fusion (PDF) are effective for treating thoracic myelopathy, surgical treatment has a high risk of various complications. There is currently no information available on the perioperative complications in thoracic ossification of the longitudinal ligament (T-OPLL) and thoracic ossification of the ligamentum flavum (T-OLF). We evaluate the perioperative complication rate and cost between T-OPLL and T-OLF for patients underwent PDF. METHODS Patients undergoing PDF for T-OPLL and T-OLF from 2012 to 2018 were detected in Japanese nationwide inpatient database. One-to-one propensity score matching between T-OPLL and T-OLF was performed based on patient characteristics and preoperative comorbidities. We examined systemic and local complication rate, reoperation rate, length of hospital stays, costs, discharge destination, and mortality after matching. RESULTS In a total of 2,660 patients, 828 pairs of T-OPLL and T-OLF patients were included after matching. The incidence of systemic complications did not differ significantly between the T-OPLL and OLF groups. However, local complications were more frequently occurred in T-OPLL than in T-OLF groups (11.4% vs. 7.7% P = 0.012). Transfusion rates was also significantly higher in the T-OPLL group (14.1% vs. 9.4%, P = 0.003). T-OPLL group had longer hospital stay (42.2 days vs. 36.2 days, P = 0.004) and higher medical costs (USD 32,805 vs. USD 25,134, P < 0.001). In both T-OPLL and T-OLF, the occurrence of perioperative complications led to longer hospital stay and higher medical costs. While fewer patients in T-OPLL were discharged home (51.6% vs. 65.1%, P < 0.001), patients were transferred to other hospitals more frequently (47.5% vs. 33.5%, P = 0.001). CONCLUSION This research identified the perioperative complications of T-OPLL and T-OLF in PDF using a large national database, which revealed that the incidence of local complications was higher in the T-OPLL patients. Perioperative complications resulted in longer hospital stays and higher medical costs.
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Affiliation(s)
- Shingo Morishita
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Toshitaka Yoshii
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
| | - Hiroyuki Inose
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Takashi Hirai
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kentaro Yamada
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yu Matsukura
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Satoru Egawa
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Jun Hashimoto
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Takuya Takahashi
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Takahisa Ogawa
- Department of Orthopedic Surgery, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
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Rujeedawa T, Mowforth OD, Davies BM, Yang C, Nouri A, Francis JJ, Aarabi B, Kwon BK, Harrop J, Wilson JR, Martin AR, Rahimi-Movaghar V, Guest JD, Fehlings MG, Kotter MR. Degenerative Thoracic Myelopathy: A Scoping Review of Epidemiology, Genetics, and Pathogenesis. Global Spine J 2024; 14:1664-1677. [PMID: 38146739 DOI: 10.1177/21925682231224768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
STUDY DESIGN Literature Review. OBJECTIVE Myelopathy affecting the thoracic spinal cord can arise secondary to several aetiologies which have similar presentation and management. Consequently, there are many uncertainties in this area, including optimal terminology and definitions. Recent collaborative cervical spinal research has led to the proposal and subsequent community adoption of the name degenerative cervical myelopathy(DCM), which has facilitated the establishment of internationally-agreed research priorities for DCM. We put forward the case for the introduction of the term degenerative thoracic myelopathy(DTM) and degenerative spinal myelopathy(DSM) as an umbrella term for both DCM and DTM. METHODS Following PRISMA guidelines, a systematic literature search was performed to identify degenerative thoracic myelopathy literature in Embase and MEDLINE. RESULTS Conditions encompassed within DTM include thoracic spondylotic myelopathy, ossification of the posterior longitudinal ligament, ossification of the ligamentum flavum, calcification of ligaments, hypertrophy of ligaments, degenerative disc disease, thoracic osteoarthritis, intervertebral disc herniation, and posterior osteophytosis. The classic presentation includes girdle pain, gait disturbance, leg weakness, sensory disturbance, and bladder or bowel dysfunction, often with associated back pain. Surgical management is typically favoured with post-surgical outcomes dependent on many factors, including the causative pathology, and presence of additional stenosis. CONCLUSION The clinical entities encompassed by the term DTM are interrelated, can manifest concurrently, and present similarly. Building on the consensus adoption of DCM in the cervical spine and the recent proposal of degenerative cervical radiculopathy(DCR), extending this common nomenclature framework to the terms degenerative spinal myelopathy and degenerative thoracic myelopathy will help improve recognition and communication.
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Affiliation(s)
- Tanzil Rujeedawa
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Oliver D Mowforth
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Benjamin M Davies
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Cylene Yang
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Aria Nouri
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Jibin J Francis
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Brian K Kwon
- Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - James Harrop
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Allan R Martin
- Department of Neurosurgery, University of California Davis, Sacramento, CA, USA
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - James D Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Michael G Fehlings
- Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mark R Kotter
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Takenaka S, Kaito T, Fujimori T, Kanie Y, Okada S. Risk Factor Analysis of Surgery-related Complications in Primary Thoracic Spine Surgery for Degenerative Diseases and Characteristics of the Patients Also Undergoing Surgery on the Cervical and/or Lumbar Spine. Clin Spine Surg 2024; 37:E170-E178. [PMID: 38158614 DOI: 10.1097/bsd.0000000000001570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/06/2023] [Indexed: 01/03/2024]
Abstract
STUDY DESIGN A retrospective cohort study using prospectively collected data. OBJECTIVE This study primarily aimed to investigate the risk factors for surgery-related complications in primary thoracic spine surgery for degenerative diseases using a surgeon-maintained database. The secondary purpose was to elucidate the characteristics of surgically treated thoracic myelopathy that also required cervical and/or lumbar spine surgery in the study period. SUMMARY OF BACKGROUND DATA Few studies reported surgical complications and the feature of tandem spinal stenosis in thoracic myelopathy in detail because of their rarity. MATERIALS AND METHODS This study included 840 thoracic myelopathy patients undergoing primary surgery for degenerative diseases from 2012 to 2021, investigating the effects of diseases, surgical procedures, and patient demographics on postoperative neurological deterioration, dural tear, dural leakage, surgical-site infection, and postoperative hematoma. In thoracic myelopathy patients who were surgically treated and also undergoing cervical and/or lumbar surgery, we investigated the proportion, the effects of diseases, and the order and intervals between surgeries. RESULTS Multivariate logistic regression revealed that significant risk factors ( P <0.05) for postoperative neurological deterioration were intervertebral disk herniation [odds ratio (OR): 4.59, 95% confidence interval (CI): 1.32-16.0) and degenerative spondylolisthesis (OR: 11.1, 95% CI: 2.15-57.5). Ossification of the ligamentum flavum (OR: 4.12, 95% CI: 1.92-8.86), anterior spinal fusion (OR: 41.2, 95% CI: 4.70-361), and circumferential decompression via a posterior approach (OR: 30.5, 95% CI: 2.27-410) were risk factors for dural tear. In thoracic myelopathy patients surgically treated, 37.0% also underwent degenerative cervical and/or lumbar surgery. CONCLUSIONS Pathologies involving anterior decompression and instability increased the risk of postoperative neurological deterioration. The risk of dural tear was increased when dura mater adhesions were likely to be directly operated upon. It should be recognized that a relatively high proportion (37.0%) of surgically treated thoracic myelopathy patients also underwent cervical and/or lumbar surgery.
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Affiliation(s)
- Shota Takenaka
- Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Asanuma S, Miura K, Funayama T, Koda M, Yamazaki M. Early Recurrence of Thoracic Ossification of the Ligamentum Flavum After Posterior Decompression Surgery: A Case Report. Cureus 2024; 16:e59429. [PMID: 38827003 PMCID: PMC11140434 DOI: 10.7759/cureus.59429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2024] [Indexed: 06/04/2024] Open
Abstract
Thoracic ossification of the ligamentum flavum (OLF) is known to result in spinal canal stenosis and myelopathy. It is typically treated through decompressive laminectomy and resection of the ossified ligament, which is known to improve neurological deficits. However, the recurrence of OLF post-surgery remains a relatively undocumented and complex issue. The present report describes the case of a 58-year-old male patient who had obesity (BMI 34), diabetes mellitus, and Basedow's disease. The patient presented with bilateral lower limb paresthesia and associated gait impairment, resulting in an urgent hospital admission. Imaging diagnostics identified extensive thoracic ossification of the posterior longitudinal ligament and OLF, both of which resulted in significant spinal cord compression. He underwent posterior decompression with instrumented fusion from T1 to T9 and additional laminectomy and OLF resection at T10/11. Despite an initial improvement in the postoperative period, the patient developed an epidural hematoma one week following surgery, causing significant paralysis of the lower limbs. This complication was promptly addressed with hematoma removal surgery. Six months after the initial procedure, his walking function improved significantly, but eight months after surgery, he experienced a sudden regression in motor functions due to the recurrence of OLF at T10/11, necessitating an additional posterior instrumented fusion surgery. Subsequent to the additional surgical procedure, the patient experienced an amelioration in paralysis, enabling him to ambulate with the aid of a cane. The recurrence of thoracic OLF after decompression surgery is a significant concern, especially in cases where decompression without instrumented fusion is performed. When determining the surgical procedure for thoracic OLF in cases with extensive ossification of the spinal ligaments, it is crucial to consider the degree of spontaneous fusion and mobility of the spinal segments, as demonstrated in the present case. The concentration of mechanical stress due to fusion at adjacent segments and intervertebral mobility at the thoracolumbar junction may increase the risk of OLF recurrence and should be carefully assessed preoperatively, even though posterior decompression surgery is typically considered a sufficient option for thoracic OLF.
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Affiliation(s)
- Sho Asanuma
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Kousei Miura
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Toru Funayama
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Masao Koda
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, JPN
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Zhang C, Yang S, Wang L, Wang N, Ke Z, Liu P, Zhang C, Xiong C, Zhao R, Liang H, Luo X. Preoperative Magnetic Resonance Imaging Signal Intensity Classification Is Associated With Clinical Presentation and Surgical Outcomes in Myelopathy Caused by Thoracic Ossification of Ligamentum Flavum: A Multicenter Study. Global Spine J 2023; 13:1971-1980. [PMID: 34911374 PMCID: PMC10556922 DOI: 10.1177/21925682211067752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVES To explore whether classification of the increased signal intensity (ISI) on magnetic resonance imaging (MRI) correlates with clinical presentations and outcomes in symptomatic thoracic ossification of ligamentum flavum (T-OLF) patients. METHODS All patients with symptomatic T-OLF who underwent laminectomy at four institutions were reviewed. The ISI on preoperative T2-weighted MRI was divided into 3 groups, Grade 0, none; Grade 1, light (obscure); and Grade 2, intense (bright). Neurological function before surgery and at follow-up was evaluated by the revised Japanese Orthopedic Association (JOA) score. Patients' demographics, clinical manifestations, and surgical outcomes were compared. RESULTS A total of 94 patients were involved. Preoperative MRI showed 32 patients in Grade 0, 39 patients in Grade 1, and 23 patients in Grade 2. Low extremities numbness, weakness, and clinical signs were less frequent in Grade 0 patients. The grade of ISI was correlated with the duration of symptoms and cord compression. Grade 0 patients had a better preoperative JOA score than those with ISI changes, while Grade 2 patients showed worse neurological recovery, longer duration of operation, more intraoperative blood loss, and a higher incidence of perioperative complications. CONCLUSION The classification of ISI is an effective parameter for preoperatively assessing cord compression, clinical severity, and surgical outcomes in T-OLF patients. Grade 0 patients have relatively mild neurological impairment but are more likely to be misdiagnosed. Grade 2 indicates the worst clinical impairment and neurological recovery, and implies a risky and challenging surgery.
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Affiliation(s)
- Chao Zhang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shengdong Yang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lin Wang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Nan Wang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhenyong Ke
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peng Liu
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chengmin Zhang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chuang Xiong
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Runhan Zhao
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hao Liang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoji Luo
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Ito K, Nagai S, Hachiya K, Takeda H, Kawabata S, Ikeda D, Kaneko S, Fujita N. Repeated Recurrence of Ligamentum Flavum Ossification After Posterior Spinal Surgery: A Case Report and Literature Review. JBJS Case Connect 2023; 13:01709767-202303000-00008. [PMID: 36821391 DOI: 10.2106/jbjs.cc.22.00267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
CASE Patients with myelopathy due to narrowing of the spinal canal with ossification of the ligamentum flavum (OLF) generally require surgical intervention, but surgical methods for OLF remain controversial. We discuss our experience regarding posterior fusion surgery with instrumentation for a patient with recurrent OLF at the same level after decompression surgery as well as describe the preoperative and postoperative course of this rare case. CONCLUSION Posterior decompression and fusion surgery is recommended as revision surgery for recurrent OLF at the same level after decompression surgery. A detailed surgical planning should be developed before surgery.
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Affiliation(s)
- Kei Ito
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University, Aichi, Japan
| | - Sota Nagai
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University, Aichi, Japan
| | - Kurenai Hachiya
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University, Aichi, Japan
| | - Hiroki Takeda
- Department of Spine and Spinal Cord Surgery, School of Medicine, Fujita Health University, Aichi, Japan
| | - Soya Kawabata
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University, Aichi, Japan
| | - Daiki Ikeda
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University, Aichi, Japan
| | - Shinjiro Kaneko
- Department of Spine and Spinal Cord Surgery, School of Medicine, Fujita Health University, Aichi, Japan
| | - Nobuyuki Fujita
- Department of Orthopaedic Surgery, School of Medicine, Fujita Health University, Aichi, Japan
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Feng X, Deng L, Feng H, Hu Y, Tian J, Sun L. Intraoperative neurophysiologic monitoring alteration during en bloc laminectomy surgery for thoracic ossification of ligamentum flavum. Front Surg 2022; 9:1019112. [PMID: 36238860 PMCID: PMC9551274 DOI: 10.3389/fsurg.2022.1019112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background There is real risk during en bloc resection for the treatment of thoracic ossification of ligamentum flavum (TOLF). Intraoperative neurophysiologic monitoring (IONM) has been applied to monitor neurologic functional integration of the spinal cord during surgery. However, the IONM outcome and its relationship with clinical results still needs to be investigated. The purpose of this study is to evaluate the effectiveness and usefulness of IONM in en bloc laminectomy for TOLF. Methods Data from a total of 68 patients with TOLF who received en bloc resection was collected for this retrospective study. IONM of somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs) were analyzed in different patterns of signal alerts, i.e. alert in either MEPs or SSEPs, alert in both MEPs and SSEPs, permanent alert, or recovery during surgery. Postoperative motor and sensory neurological function was evaluated in each patient immediately after surgery and at 12-month follow-up after surgery. The relationship of IONM outcomes and postoperative neurologic function were observed. Results Fifty of 68 patients did not present significant changes over alert criteria of IONM, neither SSEPs nor MEPs. Those 50 patients without IONM alerts did not show post-operative neurologic deterioration. Four patients presented alert of IONM in a single modality, while 2 patients showed only SSEP alert and 2 patients showed only MEP alert. Fourteen patients showed alerts in both SSEP and MEP, while 8 patients showed one or both signals return to normal during surgery and other 6 showed permanent abnormal electrophysiologic signals to the end of surgery. In the follow-up neurologic test, 3 patients presented transient neurologic complications from among 8 patients with both SSEP and MEP alerts and recovery during surgery. Six patients without recovery of IONM showed permanent neurologic complications after surgery. Conclusions Results of this study prove the effectiveness and usefulness of IONM in in en bloc laminectomy surgery for TOLF. The patterns of IONM changes correlated with postoperative neurologic functions. Special attention must be paid to the rapid loss of IONM without recovery during spinal decompression.
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Affiliation(s)
- Xiaoning Feng
- Department of Orthopedics, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Li Deng
- Department of Orthopedics, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Haoyu Feng
- Department of Orthopedics, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Yong Hu
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Jianghua Tian
- Department of Orthopedics, Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Lin Sun
- Department of Orthopedics, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Correspondence: Lin Sun
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10
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Treatment for the Thoracic Ossification of the Posterior Longitudinal Ligament and Ossification of the Ligamentum Flavum. J Clin Med 2022; 11:jcm11164690. [PMID: 36012929 PMCID: PMC9409849 DOI: 10.3390/jcm11164690] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022] Open
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11
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Transcranial Motor-evoked Potential Alert After Supine-to-Prone Position Change During Thoracic Ossification in Posterior Longitudinal Ligament Surgery: A Prospective Multicenter Study of the Monitoring Committee of the Japanese Society for Spine Surgery and Related Research. Spine (Phila Pa 1976) 2022; 47:1018-1026. [PMID: 34610608 DOI: 10.1097/brs.0000000000004246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/19/2021] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, multicenter study. OBJECTIVE To evaluate the usefulness of transcranial motor-evoked potentials (Tc-MEPs) during supine-to-prone position change for thoracic ossification of the posterior longitudinal ligament (T-OPLL). SUMMARY OF BACKGROUND DATA Supine-to-prone position change might be a risk of spinal cord injury in posterior decompression and fusion surgeries for T-OPLL. METHODS The subjects were 145 patients with T-OPLL surgically treated with posterior decompression and fusion using Tc-MEPs in 14 institutes. Tc-MEPs were monitored before surgery from supine-to-prone position and intraoperatively in seven institutes and only intraoperatively in the other seven institutes because of disapproval of the anesthesia department. In cases of Tc-MEP alert after position change, we adjusted the cervicothoracic posture. When the MEP did not recover, we reverted the position to supine and monitored the Tc-MEPs in supine position. RESULTS There were 83 and 62 patients with/without Tc-MEP before position change to prone (group A and B). The true-positive rate was lower in group A than group B, but without statistical significance (8.4% vs. 16.1%, P = 0.12). In group A, five patients who had Tc-MEP alert during supine-to-prone position change were all female and had larger body mass index values and upper thoracic lesions. Among the patients, three underwent surgeries after cervicothoracic alignment adjustment, and two had postponed operations to 1 week later with halo-vest fixation because of repeated Tc-MEP alerts during position change to prone. The Tc-MEP alert at exposure was statistically more frequent in group B than in group A ( P = 0.033). CONCLUSION Tc-MEP alert during position change is an important sign of spinal cord injury due to alignment change at the upper thoracic spine. Tc-MEP monitoring before supine-to-prone position change was necessary to prevent spinal cord injury in surgeries for T-OPLL.
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12
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Ossified Ligamentum Flavum: Epidemiology, Treatment, and Outcomes. J Am Acad Orthop Surg 2022; 30:e842-e851. [PMID: 35298441 DOI: 10.5435/jaaos-d-21-01253] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/13/2022] [Indexed: 02/01/2023] Open
Abstract
Ossification of the ligamentum flavum (OLF) is an uncommon but potentially serious spinal condition which can cause progressive compression of the spinal canal with associated devastating neurologic compromise. Although debate exists regarding the exact etiology of OLF, overexpression of genes and transcription factors centered around the Notch and Wnt signaling pathways because of increased mechanical stress seems to be related. There are many clinical and radiographic presentations of OLF; however, progressive myelopathy is the most commonly encountered. Radiographic analysis may reveal isolated OLF or OLF combined with ossification of other areas of the spine, such as disk, posterior longitudinal ligament, and dura. When surgery is necessary for OLF, several surgical strategies exist including open laminectomy with excision, endoscopic decompression, Bridge Crane resection, en block resection, and combined anterior and posterior approaches. Resection may be complicated by dural adhesion or dural ossification, and postoperative neurologic deficits are not uncommon.
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13
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Yang FK, Li PF, Dou CT, Yu RB, Chen B. Comparison of percutaneous endoscopic thoracic decompression and posterior thoracic laminectomy for treating thoracic ossification of the ligamentum flavum: a retrospective study. BMC Surg 2022; 22:85. [PMID: 35246092 PMCID: PMC8895858 DOI: 10.1186/s12893-022-01532-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/25/2022] [Indexed: 11/11/2022] Open
Abstract
Background Thoracic spinal stenosis (TSS) caused by ossification of the ligamentum flavum (OLF) is generally treated by surgical decompression. In this study, we compared the efficacy and safety of percutaneous endoscopic thoracic decompression (PETD) and posterior thoracic laminectomy (PTL) for treating thoracic ossification of the ligamentum flavum (TOLF). Methods Twenty consecutive patients with TSS caused by TOLF who were treated between April 2016 and May 2020 were included in this retrospective study. They were divided into the PETD (n = 11) and PTL (n = 9) groups. The mean follow-up period was 19.6 months. The visual analogue scale (VAS) score, the modified Japanese Orthopedic Association (mJOA) score and the recovery rate (RR) were used to evaluate the clinical outcomes. Results There were significant differences between PETD group and PTL group in operative time (min) (95.0 ± 18.8 vs 131.1 ± 19.0), postoperative drainage (mL) (20.2 ± 7.9 vs 586.1 ± 284.2), hospital stay (days) (4.4 ± 1.2 vs 10.4 ± 2.6) (P < 0.05 for all). However, both groups had similar and significant improvement in VAS and mJOA scores. The RR of two groups achieved the same improvement (81.8% VS 77.8%, P > 0.05). Conclusions The use of PETD and PTL for treating TOLF both achieved favorable outcomes. PETD is both minimally invasive and achieves similar postoperative symptom relief to PTL. Therefore, PETD could be considered as an effective alternative to traditional open surgery for TOLF in single-segment lower thoracic spine.
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Affiliation(s)
- Feng-Kai Yang
- Department of Minimally Invasive Spine Surgery, Affiliated Hospital of Chengde Medical University, Chengde, 067000, Hebei, China
| | - Peng-Fei Li
- Department of Minimally Invasive Spine Surgery, Affiliated Hospital of Chengde Medical University, Chengde, 067000, Hebei, China
| | - Chen-Tao Dou
- Department of Minimally Invasive Spine Surgery, Affiliated Hospital of Chengde Medical University, Chengde, 067000, Hebei, China
| | - Rong-Bo Yu
- Department of Minimally Invasive Spine Surgery, Affiliated Hospital of Chengde Medical University, Chengde, 067000, Hebei, China
| | - Bin Chen
- Department of Minimally Invasive Spine Surgery, Affiliated Hospital of Chengde Medical University, Chengde, 067000, Hebei, China.
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14
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Nakashima H, Imagama S, Yoshii T, Egawa S, Sakai K, Kusano K, Nakagawa Y, Hirai T, Wada K, Katsumi K, Fujii K, Kimura A, Furuya T, Kanchiku T, Nagamoto Y, Oshima Y, Nagoshi N, Ando K, Takahata M, Mori K, Nakajima H, Murata K, Matsunaga S, Kaito T, Yamada K, Kobayashi S, Kato S, Ohba T, Inami S, Fujibayashi S, Katoh H, Kanno H, Li Y, Yatsuya H, Koda M, Kawaguchi Y, Takeshita K, Matsumoto M, Yamazaki M, Okawa A. Comparison of laminoplasty and posterior fusion surgery for cervical ossification of posterior longitudinal ligament. Sci Rep 2022; 12:748. [PMID: 35031694 PMCID: PMC8760337 DOI: 10.1038/s41598-021-04727-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022] Open
Abstract
This prospective multicenter study, established by the Japanese Ministry of Health, Labour and Welfare and involving 27 institutions, aimed to compare postoperative outcomes between laminoplasty (LM) and posterior fusion (PF) for cervical ossification of the posterior longitudinal ligament (OPLL), in order to address the controversy surrounding the role of instrumented fusion in cases of posterior surgical decompression for OPLL. 478 patients were considered for participation in the study; from among them, 189 (137 and 52 patients with LM and PF, respectively) were included and evaluated using the Japanese Orthopaedic Association (JOA) scores, the JOA Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), and radiographical measurements. Basic demographic and radiographical data were reviewed, and the propensity to choose a surgical procedure was calculated. Preoperatively, there were no significant differences among the participants in terms of patient backgrounds, radiographical measurements (K-line or cervical alignment on X-ray, OPLL occupation ratio on computed tomography, increased signal intensity change on magnetic resonance imaging), or clinical status (JOA score and JOACMEQ) after adjustments. The overall risk of perioperative complications was found to be lower with LM (odds ratio [OR] 0.40, p = 0.006), and the rate of C5 palsy occurrence was significantly lower with LM (OR 0.11, p = 0.0002) than with PF. The range of motion (20.91° ± 1.05° and 9.38° ± 1.24°, p < 0.0001) in patients who had PF was significantly smaller than in those who had LM. However, multivariable logistic regression analysis showed no significant difference among the participants in JOA score, JOA recovery rate, or JOACMEQ improvement at two years. In contrast, OPLL progression was greater in the LM group than in the PF group (OR 2.73, p = 0.0002). Both LM and PF for cervical myelopathy due to OPLL had resulted in comparable postoperative outcomes at 2 years after surgery.
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Affiliation(s)
- Hiroaki Nakashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa Ward, Nagoya, Aichi, 466-8550, Japan.
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa Ward, Nagoya, Aichi, 466-8550, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
| | - Satoru Egawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
| | - Kenichiro Sakai
- Department of Orthopaedic Surgery, Saiseikai Kawaguchi General Hospital, 5-11-5 Nishikawaguchi, Kawaguchishi, Saitama, 332-8558, Japan
| | - Kazuo Kusano
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudanminami, Chiyodaku, 102-0074, Japan
| | - Yukihiro Nakagawa
- Department of Orthopaedic Surgery, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Itogun, Wakayama, 649-7113, Japan
| | - Takashi Hirai
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
| | - Kanichiro Wada
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan
| | - Keiichi Katsumi
- Department of Orthopaedic Surgery, Niigata University Medicine and Dental General Hospital, 1-754 Asahimachidori, Chuo Ward, Niigata, Niigata, 951-8520, Japan
| | - Kengo Fujii
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Atsushi Kimura
- Department of Orthoaedics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo Ward, Chiba, Chiba, 260-8670, Japan
| | - Tsukasa Kanchiku
- Department of Orthopaedic Surgery, Yamaguchi University School of Medicine, 111 Minami Kogushi, Ube, Yamaguchi, 755-8505, Japan
| | - Yukitaka Nagamoto
- Department of Orthopaedic Surgery, Osaka Rosai Hospital, 1179-3 Nagasonecho, Sakaishi, Osaka, 591-8025, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku Ward, Tokyo, 160-8582, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa Ward, Nagoya, Aichi, 466-8550, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Sapporo, 060-8638, Japan
| | - Kanji Mori
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Kazuma Murata
- Department of Orthopaedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Shunji Matsunaga
- Department of Orthopaedic Surgery, Imakiire General Hospital, 4-16 Shimotatsuocho, Kagoshimashi, 892-8502, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
| | - Kei Yamada
- Department of Orthopaedic Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka, 830-0011, Japan
| | - Sho Kobayashi
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3125, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Tetsuro Ohba
- Department of Orthopaedic Surgery, University of Yamanashi, 1110 Shimokato, Chuo Ward, Yamanashi, 409-3898, Japan
| | - Satoshi Inami
- Department of Orthopaedic Surgery, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu-machi, Shimotsuga-gun, Tochigi, 321-0293, Japan
| | - Shunsuke Fujibayashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hiroyuki Katoh
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Haruo Kanno
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryomachi, Aoba Ward, Sendai, Miyagi, 980-8574, Japan
| | - Yuanying Li
- Department of Public Health, Fujita Health University School of Medicine, Aichi, Japan
| | - Hiroshi Yatsuya
- Department of Public Health, Fujita Health University School of Medicine, Aichi, Japan.,Department of Public Health and Health Systems, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masao Koda
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yoshiharu Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Katsushi Takeshita
- Department of Orthoaedics, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku Ward, Tokyo, 160-8582, Japan
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Atsushi Okawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
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15
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Ando K, Nakashima H, Machino M, Ito S, Segi N, Tomita H, Koshimizu H, Imagama S. Postoperative progression of ligamentum flavum ossification after posterior instrumented surgery for thoracic posterior longitudinal ligament ossification: long-term outcomes during a minimum 10-year follow-up. J Neurosurg Spine 2021:1-11. [PMID: 34952516 DOI: 10.3171/2021.10.spine211091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to investigate clinical and radiological outcomes after thoracic posterior fusion surgery during a minimum of 10 years of follow-up, including postoperative progression of ossification, in patients with thoracic ossification of the posterior longitudinal ligament (T-OPLL). METHODS The study participants were 34 consecutive patients (15 men, 19 women) with an average age at surgery of 53.6 years (range 36-80 years) who underwent posterior decompression and fusion surgery with instrumentation at the authors' hospital. The minimum follow-up period was 10 years. Estimated blood loss, operative time, pre- and postoperative Japanese Orthopaedic Association (JOA) scores, and JOA score recovery rates were investigated. Dekyphotic changes were evaluated on plain radiographs of thoracic kyphotic angles and fusion levels pre- and postoperatively and 10 years after surgery. The distal junctional angle (DJA) was measured preoperatively and at 10 years after surgery to evaluate distal junctional kyphosis (DJK). Ossification progression at distal intervertebrae was investigated on CT. RESULTS The Cobb angles at T1-12 were 46.8°, 38.7°, and 42.6°, and those at the fusion level were 39.6°, 31.1°, and 34.1° pre- and postoperatively and at 10 years after surgery, respectively. The changes in the kyphotic angles from pre- to postoperatively and to 10 years after surgery were 8.0° and 7.2° at T1-12 and 8.4° and 7.9° at the fusion level, respectively. The DJA changed from 4.5° postoperatively to 10.9° at 10 years after surgery. There were 11 patients (32.3%) with DJK during follow-up, including 4 (11.8%) with vertebral compression fractures at lower instrumented vertebrae or adjacent vertebrae. Progression of ossification of the ligamentum flavum (OLF) on the caudal side occurred in 8 cases (23.6%), but none had ossification of the posterior longitudinal ligament (OPLL) progression. Cases with OLF progression had a significantly lower rate of DJK (0% vs 38.5%, p < 0.01), a lower DJA (3.4° vs 13.2°, p < 0.01), and a smaller change in DJA at 10 years after surgery (0.8° vs 8.1°, p < 0.01). CONCLUSIONS Posterior decompression and fusion surgery with instrumentation for T-OPLL was found to be a relatively safe and stable surgical procedure based on the long-term outcomes. Progression of OLF on the caudal side occurred in 23.6% of cases, but cases with OLF progression did not have DJK. Progression of DJK shifts the load in the spinal canal forward and the load on the ligamentum flavum is decreased. This may explain the lack of ossification in cases with DJK.
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16
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Zhang B, Chen G, Chen X, Yang X, Fan T, Sun C, Chen Z. Integrating Bioinformatic Strategies with Real-World Data to Infer Distinctive Immunocyte Infiltration Landscape and Immunologically Relevant Transcriptome Fingerprints in Ossification of Ligamentum Flavum. J Inflamm Res 2021; 14:3665-3685. [PMID: 34354364 PMCID: PMC8331123 DOI: 10.2147/jir.s318009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/08/2021] [Indexed: 12/31/2022] Open
Abstract
Purpose Ossification of the ligamentum flavum (OLF) is a multifactorial disease characterized by an insidious and debilitating process of abnormal bone formation in ligamentum tissues. However, its definite pathogenesis has not been fully elucidated. Potential links between the immune system and various forms of heterotopic ossification have been discussed for many years, whereas no research investigated the immune effects on the initiation and development of OLF. Therefore, we attempt to shed light on this issue. Methods A series of bioinformatic algorithms were integrated to evaluate the immune score and the immunocyte infiltration patterns between OLF and normal samples, screen OLF-related and immune-related differentially expressed genes (OIDEGs), and analyze their biological functions. Correlation analysis inferred OIDEGs-related differentially expressed lncRNAs (OIDELs) and infiltrating immune cells (OIICs) to construct an immunoregulatory network. Results Differential immune score and immune cell infiltration were determined between two groups, and 10 OIDEGs with diverse biological function annotations were identified and verified. A lncRNA-gene-immunocyte regulatory network further revealed 10 OIDEGs, 41 OIDELs and 7 OIICs that were highly correlated. Among them, CD1E and STAT3 were predicted as hub genes whether at the expression level or interaction level. cDCs emerged as having the most prominent differences and the highest degree of connectivity. FO393414.3, AC096734.1, LINC01137 and DLX6-AS1 with the greatest number of OIDEGs were thought to be more likely to participate in immunoregulation of OLF. Conclusion This is the first research to preliminarily elucidate OLF-related immunocyte infiltration landscape and immune-associated transcriptome signatures based on bioinformatic strategies and real-world data, which may provide compelling insights into the pathogenesis and therapeutic targets of OLF.
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Affiliation(s)
- Baoliang Zhang
- Peking University Third Hospital, Department of Orthopaedics, Beijing, 100191, People's Republic of China.,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191, People's Republic of China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, People's Republic of China
| | - Guanghui Chen
- Peking University Third Hospital, Department of Orthopaedics, Beijing, 100191, People's Republic of China.,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191, People's Republic of China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, People's Republic of China
| | - Xi Chen
- Peking University Third Hospital, Department of Orthopaedics, Beijing, 100191, People's Republic of China.,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191, People's Republic of China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, People's Republic of China
| | - Xiaoxi Yang
- Peking University Third Hospital, Department of Orthopaedics, Beijing, 100191, People's Republic of China.,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191, People's Republic of China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, People's Republic of China
| | - Tianqi Fan
- Peking University Third Hospital, Department of Orthopaedics, Beijing, 100191, People's Republic of China.,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191, People's Republic of China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, People's Republic of China
| | - Chuiguo Sun
- Peking University Third Hospital, Department of Orthopaedics, Beijing, 100191, People's Republic of China.,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191, People's Republic of China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, People's Republic of China
| | - Zhongqiang Chen
- Peking University Third Hospital, Department of Orthopaedics, Beijing, 100191, People's Republic of China.,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191, People's Republic of China.,Beijing Key Laboratory of Spinal Disease Research, Beijing, 100191, People's Republic of China
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17
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Miyoshi S, Morino T, Takeda H, Nakata H, Hino M, Misaki H, Murakami Y, Imai H, Miura H. Thoracic spondylotic myelopathy presumably caused by diffuse idiopathic skeletal hyperostosis in a patient who underwent decompression and percutaneous pedicle screw fixation. SAGE Open Med Case Rep 2021; 9:2050313X20987796. [PMID: 33628446 PMCID: PMC7829458 DOI: 10.1177/2050313x20987796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/22/2020] [Indexed: 11/17/2022] Open
Abstract
A 74-year-old man developed bilateral lower limb spastic paresis. He was diagnosed with
thoracic spondylotic myelopathy presumably caused by mechanical stress that was generated
in the intervertebral space (T1-T2) between a vertebral bone bridge (C5-T1) due to diffuse
idiopathic skeletal hyperostosis after anterior fixation of the lower cervical spine and a
vertebral bone bridge (T2-T7) due to diffuse idiopathic skeletal hyperostosis in the upper
thoracic spine. Treatment included posterior decompression (T1-T2 laminectomy) and
percutaneous pedicle screw fixation at the C7-T4 level. Six months after surgery, the
patient could walk with a cane, and the vertebral bodies T1-T2 were bridged without bone
grafting. For thoracic spondylotic myelopathy associated with diffuse idiopathic skeletal
hyperostosis, decompression and percutaneous pedicle screw fixation are effective
therapies.
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Affiliation(s)
- Shota Miyoshi
- Department of Orthopedic Surgery, Saijo Central Hospital, Saijo, Japan
| | - Tadao Morino
- Department of Orthopedic Surgery, Ehime University School of Medicine, Tohon, Japan
| | - Haruhiko Takeda
- Department of Orthopedic Surgery, Saijo Central Hospital, Saijo, Japan
| | - Hiroshi Nakata
- Department of Orthopedic Surgery, Saijo Central Hospital, Saijo, Japan
| | - Masayuki Hino
- Department of Orthopedic Surgery, Ehime University School of Medicine, Tohon, Japan
| | - Hiroshi Misaki
- Department of Orthopedic Surgery, Ehime University School of Medicine, Tohon, Japan
| | - Yusuke Murakami
- Department of Orthopedic Surgery, Ehime University School of Medicine, Tohon, Japan
| | - Hiroshi Imai
- Department of Orthopedic Surgery, Ehime University School of Medicine, Tohon, Japan
| | - Hiromasa Miura
- Department of Orthopedic Surgery, Ehime University School of Medicine, Tohon, Japan
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Wang L, Wang H, Chen Z, Sun C, Li W. Surgical strategy for non-continuous thoracic spinal stenosis: one- or two-stage surgery? INTERNATIONAL ORTHOPAEDICS 2021; 45:1871-1880. [PMID: 33427901 DOI: 10.1007/s00264-020-04913-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Non-continuous thoracic spinal stenosis (NTSS) is a rare disease, but it is a challenging clinical entity for spine surgeons. However, few studies have focused on its treatment. Therefore, the purpose of this study was to provide surgical treatment guidelines for it by comparing the clinical outcomes of different surgical approaches. METHODS Patients who underwent thoracic decompression surgery for two diseased segments with two incisions (normal segments ≥ 3) between January 2010 and December 2018 were included. Among these patients, nine were treated with posterior decompression (PD) and circumferential decompression (CD) procedures in one-stage surgery (group A), 14 with PD and CD procedures in two-stage surgery (group B), 36 patients with PD procedures in one-stage surgery and 15 with PD procedures in two-stage surgery (group D). Medical records, operative time, blood loss and complications were reviewed. Neurologic status was assessed by the modified Japanese Orthopaedic Association scale for thoracic myelopathy. RESULTS Groups A, B, C and D were followed for 54.11 ± 20.51 months, 49.36 ± 29.30 months, 49.94 ± 31.94 months and 39.93 ± 26.18 months, respectively. When comparing groups A and B, operative time, blood loss and length of stay in hospital were significantly less in group A. However, the average recovery rate in group B was significantly higher than that in group A. In regard to groups C and D, group C showed a significantly shorter length of stay in hospital and lower rate of post-operative neurological deterioration. At final follow-up, groups C and D showed similar average recovery rates. CONCLUSION Different surgical procedures are suitable for different types of NTSS. For patients with NTSS mainly caused by posterior compression, PD via laminectomy in one-stage with two incisions can achieve satisfying clinical outcomes. Staged surgery, including CD and PD procedures, is recommended for patients with NTSS mainly caused by anterior compression.
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Affiliation(s)
- Longjie Wang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China
| | - Hui Wang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China
| | - Zhongqiang Chen
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China
| | - Chuiguo Sun
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China
| | - Weishi Li
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China. .,Beijing Key Laboratory of Spinal Disease Research, Beijing, China.
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Bilateral translaminar osseous-channel assisted percutaneous full-endoscopic ligamentectomy decompression for thoracic myelopathy due to ossification of the ligamentum flavum: a technical note. Wideochir Inne Tech Maloinwazyjne 2020; 16:429-441. [PMID: 34136042 PMCID: PMC8193760 DOI: 10.5114/wiitm.2020.100719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 09/20/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction A variety of surgical procedures have been introduced to treat patients with thoracic myelopathy (TM) caused by ossification of the ligamentum flavum (OLF). However, they are accompanied by significant trauma and risk, and their surgical outcomes are not always satisfactory. Aim To describe a bilateral translaminar osseous-channel assisted posterior percutaneous full-endoscopic ligamentectomy decompression (p-PELD) technique as a novel minimally invasive procedure for treating patients with TM due to OLF. Material and methods A 51-year-old female patient with persistent thoracolumbar back pain and progressive numbness in the bilateral lower extremities for 2 years underwent percutaneous vertebroplasty (PVP) for T11 osteoporotic compression fractures (OCF) in a regional hospital one week prior to hospitalization. TM caused by canal stenosis and dorsal spinal cord compression at T10/11 secondary to OLF and an OCF at T11 were diagnosed based on clinical presentations and radiologic examinations. After bilateral p-PELD for TM was performed at T10/11, the result was confirmed based on postoperative radiographic and clinical results. Results The bilateral OLF was completely removed by the p-PELD technique. No complications were encountered, and her symptoms were sufficiently improved after surgery. The VAS score was 6 points preoperatively and decreased to 0 points at the last follow-up (24 months). The modified Japanese Orthopaedic Association (mJOA) score improved from 2 points preoperatively to 10 points at the final follow-up. Conclusions As a minimally invasive technique, the bilateral translaminar osseous-channel assisted p-PELD procedure provided precise and sufficient decompression for the treatment of OLF-related TM.
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Cheng XK, Bian FC, Liu ZY, Yang FK, Chen B. A comparison study of percutaneous endoscopic decompression and posterior decompressive laminectomy in the treatment of thoracic spinal stenosis. BMC Musculoskelet Disord 2020; 21:717. [PMID: 33143667 PMCID: PMC7641830 DOI: 10.1186/s12891-020-03739-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 10/23/2020] [Indexed: 11/13/2022] Open
Abstract
Background Percutaneous endoscopic decompression (PED) is considered a minimally invasive and safe procedure in lumbar degenerative disease. Few authors report the success of PED for thoracic spinal stenosis (TSS) with thoracic myelopathy. The objective of this study was to compare the outcome of PED versus posterior decompressive laminectomy (PDL) for TSS. Methods We retrospectively reviewed 30 consecutive patients who underwent surgery for single-level TSS from January 1, 2015 to May 1, 2019.These patients were divided into PED (n = 16) and PDL(n = 14) group. Preoperative demographic characteristics and perioperative outcomes were reviewed. Pre- and postoperative neurological status was evaluated using the modified Japanese Orthopaedic Association (mJOA) score and the recovery rate (RR). Results The patients’ mean age was 57.3 years (27–76) in PED group and 58.8 years (34–77) in PDL group. No statistical difference was found between two groups with regards to neurological status at pre-operative and final follow-up. The RR in PED group achieved the same improvement as PDL group (87.5% vs 85.7%, P > 0.05), while the PED brought advantages in operative time(m) (86.4 vs 132.1, p < 0.05), blood loss (mL) (18.21 vs 228.57, p < 0.05),drainage volume(mL) (15.5 vs 601.4, p < 0.05), and hospital stay (d) (3.6 vs 5.6, p < 0.05). Conclusions Both PED and PDL showed favorable outcome in the treatment of TSS. Besides, PED had advantages in reducing traumatization. In terms of perioperative quality of life, PED could be an efficient supplement to traditional posterior decompressive laminectomy in patients with TSS.
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Affiliation(s)
- Xiao-Kang Cheng
- Department of Spine Surgery, Chengde Medical University Affiliated Hospital, Chengde, 067000, Hebei Province, China.,Chengde Medical University, Chengde, 067000, Hebei, China
| | - Fu-Cheng Bian
- Department of Spine Surgery, Chengde Medical University Affiliated Hospital, Chengde, 067000, Hebei Province, China.,Chengde Medical University, Chengde, 067000, Hebei, China
| | - Zhao-Yu Liu
- Department of Spine Surgery, Chengde Medical University Affiliated Hospital, Chengde, 067000, Hebei Province, China.,Chengde Medical University, Chengde, 067000, Hebei, China
| | - Feng-Kai Yang
- Department of Spine Surgery, Chengde Medical University Affiliated Hospital, Chengde, 067000, Hebei Province, China.,Chengde Medical University, Chengde, 067000, Hebei, China
| | - Bin Chen
- Department of Spine Surgery, Chengde Medical University Affiliated Hospital, Chengde, 067000, Hebei Province, China.
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21
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miR-29a-5p Targets SATB2 and Regulates the SIRT1/Smad3 Deacetylation Pathway to Inhibit Thoracic Ligamentum Flavum Cell Osteogenesis. Spine (Phila Pa 1976) 2020; 45:E1057-E1065. [PMID: 32205703 DOI: 10.1097/brs.0000000000003505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Experimental analysis of the thoracic ligamentum flavum cell osteogenic differentiation process. OBJECTIVE This study aimed to explore the role of miR-29a-5p and special AT-rich sequence-binding protein 2 (SATB2) in a pathological osteogenic process. SUMMARY OF BACKGROUND DATA Thoracic ossification of the ligamentum flavum (TOLF) is an uncommon disease wherein ligaments within the spine undergo progressive ossification, resulting in stenosis of the spinal canal and myelopathy. MiR-29a-5p was found to be downregulated in ligament cells from ossified ligament tissue in a previous study. However, whether miR-29a-5p is involved in the process of TOLF has not been investigated. METHODS The expression of miR-29a-5p in ligament tissues or in the context of TOLF osteogenic cell differentiation was measured via qRT-PCR. Alkaline phosphatase activity assay and Alizarin red staining were used to analyze cellular osteogenesis. The protein-level expression of SATB2, SIRT1, and Smad3 were measured via immunohistochemistry or western blotting. Dual luciferase reporter assays and western blotting were used to confirm that miR-29a targets SATB2. RESULTS SATB2 was found to be upregulated and miR-29a-5p was downregulated in TOLF tissue. We additionally observed decreased miR-29a-5p expression during the process of TOLF osteogenic cell differentiation, and there was a marked reduction in the expression of key mediators of osteogenesis when miR-29a-5p was overexpressed. Consistent with this, when miR-29a-5p was inhibited this led to enhanced osteogenic cell differentiation of these cells. We further found miR-29a-5p to directly target and suppress the expression of SATB2. Knock-down of SATB2 was sufficient to reduce the ability of miR-29a-5p to inhibit osteogenesis, and this also led to decreased SIRT1 expression and Smad3 acetylation. CONCLUSION Together our findings indicate that miR-29a-5p is able to prevent thoracic ligamentum flavum cell osteogenesis at least in part via targeting SATB2 and thereby suppressing the SIRT1/Smad3 deacetylation pathway. LEVEL OF EVIDENCE N/A.
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