What Is the Impact of Surgical Approach in the Treatment of Degenerative Cervical Myelopathy in Patients With OPLL? A Propensity-Score Matched, Multi-Center Analysis on Inpatient and Post-Discharge 90-Day Outcomes

Improved Function After Anterior Controllable Antedisplacement and Fusion for Cervical Ossification of Posterior Longitudinal Ligament: A Long-Term Follow-Up

BACKGROUND

Anterior controllable antedisplacement and fusion (ACAF) is an emerging surgical approach for treating cervical ossification of the posterior longitudinal ligament (C-OPLL), yet there is limited data on its long-term efficacy and safety. The present study aimed to analyze the short- and long-term postoperative clinical and radiological outcomes and perioperative complications of ACAF for patients with C-OPLL.

METHODS

This was a single-center, retrospective, cohort study, with the mean duration of follow-up of at least 24 months. A total of 111 patients with C-OPLL in our institution from June 2017 to June 2019 were assessed preoperatively and at 3 days, 3, 6, 12, and 24 months postoperatively. The primary outcome was the recovery of neurological function, measured with the Japanese Orthopedic Association (JOA) score. The secondary outcomes included pain, Cobb angle, spinal canal invasion rate, and surgery-related complications.

RESULTS

The postoperative JOA score at each follow-up was significantly better than the preoperative JOA score, regardless of preoperative spinal canal invasion rate, K-line, and segment length. The visual analog scale (VAS) score also decreased dramatically 3 days after surgery and was maintained at a low level throughout the follow-up period. Improvements in Cobb angle and invasion rate were observed right after the operation and were maintained for 2 years thereafter.

CONCLUSIONS

ACAF could achieve satisfactory recovery of neurological function in C-OPLL patients during a follow-up of 24 months, regardless of preoperative spinal canal invasion rate, preoperative K-line, or surgical segment length.

Comparison of anterior and posterior approaches for the treatment of cervical ossification of the posterior longitudinal ligament: a meta-analysis of 28 cohort studies

At present, the choice of approach for the surgical treatment of cervical ossification of the posterior longitudinal ligament (OPLL) remains controversial. We performed this meta-analysis to compare the efficacy of the anterior and posterior approaches in the treatment of cervical OPLL. PubMed, EMBASE and the Cochrane Library were systematically searched for all eligible articles as of August 3, 2023, without any publication date restrictions. We used the random effects model to pool standardized mean differences (SMDs) or odds ratios (ORs) with 95% confidence intervals (CIs). We conducted subgroup analyses to explore the potential sources of heterogeneity, and sensitivity analyses were used to evaluate the robustness of the findings via the leave-one-out procedure. In addition, we evaluated publication bias by observing the symmetry of the funnel plot and using Egger's test, and the trim-and-fill method was employed to A total of 28 studies including 6,324 participants met the inclusion criteria. The meta-analysis revealed that, compared with the posterior approach, the anterior approach was significantly associated with a superior recovery rate (SMD, 0.83; 95% CI, 0.41 to 1.25), a greater number of patients with a recovery rate ≥ 50% (OR, 2.13; 95% CI, 1.16 to 3.92), higher Japanese Orthopaedic Association (JOA) scores (SMD, 0.62; 95% CI, 0.31 to 0.94), and better recovery of cervical lordosis (SMD, 1.83; 95% CI, 0.95 to 2.72). Furthermore, the results revealed that the complication rate (OR, 1.45; 95% CI, 1.01 to 2.09) with the anterior approach was significantly greater than that with the posterior approach. However, our study revealed no significant differences between the two surgical groups in terms of the postoperative visual analogue scale (VAS) score, postoperative space available for the spinal cord, postoperative range of motion of the cervical spine, duration of symptoms, operation time, blood loss, or length of stay. The anterior approach is superior to the posterior approach in terms of the postoperative recovery rate, the number of patients with a recovery rate ≥ 50%, JOA scores, and recovery of cervical lordosis. Combined with the results of the above outcome and subgroup analysis, we advocate for the anterior approach in patients with a canal-occupying ratio exceeding 50% or 60%.

Laminoplasty with foraminotomy versus anterior cervical discectomy and fusion for cervical myeloradiculopathy

BACKGROUND CONTEXT

Anterior cervical discectomy and fusion (ACDF) combined with uncinate process resection and laminoplasty combined with foraminotomy (LPF) have been used to achieve cervical cord and root decompression in patients with combined cervical myeloradiculopathy (CMR).

PURPOSE

To compare the clinical and radiographic outcomes of ACDF with those of LPF for the treatment of CMR.

STUDY DESIGN/SETTING

Propensity score-matched retrospective cohort study.

PATIENT SAMPLE

Patients with CMR who underwent ACDF or LPF and were followed up for at least 2 years.

OUTCOME MEASURES

C2-C7 lordosis, C2-C7 sagittal vertical axis, and cervical range of motion (ROM) were determined. The visual analog scale (VAS) scores for neck and arm pain, neck disability index (NDI), and Japanese Orthopedic Association (JOA) scores were analyzed.

METHODS

The radiographic and clinical outcomes of the 2 groups were compared.

RESULTS

Eighty-four patients were included (n=42 in each group) after application of the inclusion criteria and propensity score matching. A significant decrease in C2-C7 lordosis (p<.001) and ROM (p<.001) was observed in the LPF and ACDF groups, respectively. LPF was associated with a significant decrease in C2 to C7 lordosis (p<.001), while ACDF caused a significant decrease in cervical ROM (p<.001). ACDF effectively improved neck pain VAS (p<.001) and NDI (p<.001), while neck pain did not significantly improve after LPF (p=.103). Furthermore, neck pain VAS (p=0.026) and NDI (p=.021) at postoperative 6 months, were significantly greater in the LPF group than in the ACDF group, while the difference was not statistically significant at 2 years postoperatively (neck pain VAS, p=.502; NDI, p=.085). Arm pain VAS and JOA score both significantly improved after LPF (p=0.003 and 0.043, respectively) or ACDF (p<.001 and 0.039, respectively), and postoperative results were not significantly different between the 2 groups.

CONCLUSION

LPF and ACDF yielded similar outcomes for arm pain and neurological recovery. More immediate neck pain improvement was observed with ACDF, while neck pain after 2 years postoperatively was similar between the LPF and ACDF groups. Furthermore, increased postoperative loss of lordosis was observed in the LPF group, whereas decreased postoperative ROM was observed in the ACDF group. These findings should be considered when deciding the surgical method for patients with CMR.

LEVEL OF EVIDENCE

III.

Reoperation rate and risk factors of reoperation for ossification of the posterior longitudinal ligament (OPLL): a systematic review and meta-analysis

Revision surgery for OPLL is undesirable for both patients and physicians. However, the risk factors for reoperation are not clear. Thus, we sought to review the existing literature and determine the factors associated with higher reoperation rates in patients with OPLL. A search was performed using Pubmed, Embase, Web of Sciences, and Ovid to include studies regarding the risk factors of reoperation for OPLL. RoBANS (Risk of Bias Assessment tool for Nonrandomized Studies) was used for risk of bias analysis. Heterogeneity of studies and publication bias was assessed, and sensitivity analysis was performed. Statistical analysis was performed with a p-value < 0.05 using SPSS software (version 23). Twenty studies with 129 reoperated and 2,793 non-reoperated patients were included. The pooled reoperation rate was 5% (95% CI: 4% to 7). The most common cause of reoperation was residual OPLL or OPLL progression (n = 51, 39.53%). An increased risk of additional surgery was found with pre-operative cervical or thoracic angle (Standardized mean difference = -0.44; 95% CI: -0.69 to -0.19; p = 0.0061), post-operative CSF leak (Odds ratio, OR = 4.97; 95% CI: 2.48 to 9.96; p = 0.0005), and graft and/or hardware failure (OR = 192.09; 95% CI: 6.68 to 5521.69; p = 0.0101). Apart from the factors identified in our study, the association of other variables with the risk of second surgery could not be ruled out, owing to the complexity of the relationship and significant bias in the current literature.

Nationwide sample data analysis of additional surgery rate after anterior or posterior cervical spinal surgery

Surgical outcomes of degenerative cervical spinal disease are dependent on the selection of surgical techniques. Although a standardized decision cannot be made in an actual clinical setting, continued education is provided to standardize the medical practice among surgeons. Therefore, it is necessary to supervise and regularly update overall surgical outcomes. This study aimed to compare the rate of additional surgery between anterior and posterior surgeries for degenerative cervical spinal disease using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) nationwide patient database. The NHIS-NSC is a population-based cohort with about a million participants. This retrospective cohort study included 741 adult patients (> 18 years) who underwent their first cervical spinal surgery for degenerative cervical spinal disease. The median follow-up period was 7.3 years. An event was defined as the registration of any type of cervical spinal surgery during the follow-up period. Event-free survival analysis was used for outcome analysis, and the following factors were used as covariates for adjustment: location of disease, sex, age, type of insurance, disability, type of hospital, Charles comorbidity Index, and osteoporosis. Anterior cervical surgery was selected for 75.0% of the patients, and posterior cervical surgery for the remaining 25.0%. Cervical radiculopathy due to foraminal stenosis, hard disc, or soft disc was the primary diagnosis in 78.0% of the patients, and central spinal stenosis was the primary diagnosis in 22.0% of them. Additional surgery was performed for 5.0% of the patients after anterior cervical surgery and 6.5% of the patients after posterior cervical surgery (adjusted subhazard ratio, 0.83; 95% confidence interval, 0.40-1.74). The rates of additional surgery were not different between anterior and posterior cervical surgeries. The results would be helpful in evaluating current practice as a whole and adjusting the health insurance policy.

Characteristics of the cervical spine and cervical cord injuries in older adults with cervical ossification of the posterior longitudinal ligament

Although the incidence of cervical spinal cord injury (CSCI) with ossification of the posterior longitudinal ligament (OPLL) has increased in older adults, its etiology and neurological outcomes remain unknown. We identified OPLL characteristics and determined whether they influence neurological severity and improvement of CSCI in older patients. This multicenter retrospective cohort study identified 1512 patients aged ≥ 65 years diagnosed with CSCI on admission during 2010-2020. We analyzed CSCI etiology in OPLL patients. We performed propensity score-adjusted analyses to compare neurological outcomes between patients with and without OPLL. Cases were matched based on variables influencing neurological prognosis. The primary neurological outcome was rated according to the American Spine Injury Association (ASIA) impairment scale (AIS) and ASIA motor score (AMS). In 332 OPLL patients, the male-to-female ratio was approximately 4:1. Half of all patients displayed low-energy trauma-induced injury and one-third had CSCI without a bony injury. Propensity score matching created 279 pairs. There was no significant difference in the AIS grade and AMS between patients with and without OPLL during hospitalization, 6 months, and 12 months following injury. OPLL patients tended to exhibit worse neurological findings during injury; nevertheless, OPLL was not associated with poor neurological improvement in older CSCI patients.