Surgical decision-making for ossification of the posterior longitudinal ligament versus other types of degenerative cervical myelopathy: anterior versus posterior approaches

Correlation of imaging characteristics of degenerative cervical myelopathy and the surgical approach with improvement for postoperative neck pain and neural function: a retrospective cohort study

Background

Complex degenerative cervical spondylotic myelopathy (DCM) is characterized by a variety of complex imaging features. The surgical method for DCM remains controversial. This study aimed to examine the correlation between the imaging characteristics of DCM with varying degrees of complexity and the surgical approach and clinical outcome.

Methods

A retrospective cohort study involving retrospective data collection was performed. A total of 139 patients with DCM who underwent surgery between January 2015 and January 2018 in the Orthopedics Department of Shanxi Bethune Hospital were divided into 3 groups according to the complexity of imaging features: 18 patients in the mild group, 66 patients in the moderate group, and 55 patients in the severe group. The Visual Analog Scale (VAS) and Japanese Orthopaedic Association (JOA) scores were used to compare the effects of neck pain and neural function prior to surgery according to the rate of improvement as of the last follow-up. Routine X-ray films were obtained at the follow-up of 3-6 months. The necessity of computed tomography (CT) and magnetic resonance imaging (MRI) examinations was determined based on clinical findings and X-ray images. Analysis of variance (ANOVA) was used to compare groups, the least significant difference (LSD) test was used for multiple comparisons, and the Chi-square test was used to compare classification indicators (imaging manifestations, gender), with P<0.05 being statistically significant. Binary logistic regression analysis was performed to determine the primary influencing factors of the JOA recovery rate.

Results

In all three groups, JOA and VAS scores at the final follow-up were significantly higher than those before surgery (P<0.001). There were significant differences in the preoperative VAS and JOA scores between any two groups, as well as in the VAS and JOA scores and improvement rates at the last follow-up between the mild group and the moderate group and between the mild group and the severe group (P<0.001). Age, preoperative JOA scores, MRI intramedullary hyperintensity signal, and the degree of spinal cord compression were primarily related to the nervous system recovery rate (P<0.001).

Conclusions

Age, MRI intramedullary hyperintensity signal, degree of spinal cord compression, and other variables were associated with the improvement of neural function in patients with DCM. Therefore, in addition to the JOA improvement rate or VAS score, additional factors, such as the patient's condition, the improvement in quality of life, and the patient's financial capacity, should be considered in evaluating the improvement of postoperative neck pain and neural function.

A Novel Posterior Compression Score System for Outcome Prediction in Laminoplasty Treated OPLL Patients: A Propensity-Matched Analysis

STUDY DESIGN

A retrospective observational study.

OBJECTIVE

To describe a novel outcome indication system, the posterior compression score (PCS), and investigate its clinical value in cervical ossification of the posterior longitudinal ligament (OPLL) patients treated with laminoplasty.

METHODS

A total of 282 OPLL patients who underwent laminoplasty from January 2013 to December 2018 were reviewed. The patients were divided into high-score (HS) or low-score (LS) groups based on whether the PCS was over 8. Propensity score matching analysis with a caliper of .1 was used to attenuate the potential selection bias. Clinical measurements, including the Japanese Orthopedic Association (JOA) score, visual analog scale (VAS), neck disability index (NDI), and radiological measurements, including C2-C7 lordotic angle and range of motion (ROM), were compared between the groups.

RESULTS

The mean follow-up period was 29.87 ± 9.17 months. There were no significant differences between the two groups regarding patients' baseline demographical and clinical characteristics after propensity score matching. No significant differences were found in the operative time, blood loss, postoperative VAS score for neck and arm pain, postoperative C2-C7 lordotic angle, or postoperative ROM (P > .05). However, the postoperative JOA score and recovery rate were significantly higher in the HS group than in the LS group, while the postoperative NDI was significantly lower in the HS group (P < .05).

CONCLUSION

OPLL patients with higher PCS scores displayed better clinical outcomes. The novel PCS system is suggested to be a reliable scoring system for surgical outcome evaluation in patients with cervical OPLL.

Assessing Range of Motion Gap in Circumferential Surgery for Cervical Myelopathy due to Ossification of the Posterior Longitudinal Ligament

OBJECTIVE

Only a few studies have investigated the gap range of motion (gROM) in cervical myelopathy or deformity caused by ossification of the posterior longitudinal ligament (OPLL). The aim of this study is to investigate the correlation between the individual gROM and the postoperative clinical outcomes of patients with OPLL.

METHODS

Consecutive patients of cervical myelopathy caused by OPLL were analyzed retrospectively. The clinical outcomes were evaluated using Visual Analogue Scale scores of the neck and arm pain and the Japanese Orthopaedic Association scores. Radiologic measurements included flexion ROM (fROM), which was defined as the difference of cervical lordosis in flexion and neutral positions, extension ROM (eROM), defined as the difference between neutral and extension positions, and gROM, defined as the difference between fROM and eROM. Patients were grouped by the values of gROM, and comparisons of all outcomes were made between the groups.

RESULTS

A total of 42 patients underwent surgery. The patients with greater gROM did not differ from those with smaller gROM by demographic characteristics. During follow-up (mean 45.8 months), both groups had similar improvements, but the C5 palsy rates were higher in the greater gROM group than in the smaller gROM group (71% and 22%, P < 0.05).

CONCLUSIONS

Simultaneous circumferential decompression and fixation is an effective surgical option for patients with cervical myelopathy caused by OPLL. A higher rate of postoperative C5 palsy was observed in the patients with greater gROMs after surgery, although all patients presented with similar clinical improvements.

Management of Cerebrospinal Fluid Leakage by Pump-Regulated Volumetric Continuous Lumbar Drainage Following Anterior Cervical Decompression and Fusion for Ossification of the Posterior Longitudinal Ligament

OBJECTIVE

Cerebrospinal fluid (CSF) leakage is a major concern related to anterior cervical decompression and fusion for ossification of the posterior longitudinal ligament (OPLL). We propose a management algorithm for CSF leakage following anterior cervical decompression and fusion for OPLL involving the use of pump-regulated volumetric continuous lumbar drainage.

METHODS

We retrospectively reviewed patients who underwent anterior cervical decompression and fusion for OPLL and were managed with the proposed algorithm between March 2018 and July 2022. The proposed management algorithm for CSF leakage by pump-regulated volumetric continuous lumbar drainage was as follows. On exposure of the arachnoid membrane with or without CSF leakage, a dural sealant patch was applied to manage the dural defect. In case of persistent CSF leakage despite application of the dural sealant patch, patients underwent pump-regulated volumetric continuous lumbar drainage.

RESULTS

Fifty-one patients were included in the study. CSF leakage occurred in 14 patients. Of these 14 patients, 9 patients underwent lumbar drain insertion according to the proposed management algorithm. Successful resolution of CSF leakage was observed in 8 of the 9 patients who underwent lumbar drainage. All patients were encouraged to ambulate without concern of CSF overdrainage due to gravity, because it could be avoided with pump-regulated volumetric continuous CSF drainage. Therefore, complications associated with absolute bed rest or CSF overdrainage were not observed.

CONCLUSION

The proposed management algorithm with pump-regulated volumetric continuous lumbar drainage showed safety and efficacy for management of CSF leakage following anterior decompression and fusion for OPLL.

Minimally invasive fenestration for decompression of C2-C3 spinal stenosis

Conventional techniques in neurosurgery such as laminectomy have been extensively displaced by minimally invasive types, owing to the character of complexity of cervical spinal region. Spinal canal stenosis at C2-C3 level is documented in the literature with the majority being caused by intervertebral disc herniations.This case reports a patient who presented with classical myelopathy symptoms and significant thickening of ligamentum flavum, while minimal spondylosis was detected at C2-C3 level. The decompression was performed from posterior approach and limited to the removal of ligamentum flavum with minimal resection of adjacent laminae, no fixation and no disc evacuation. After surgery, there was a significant improvement with preserved spinal stability.Although the anterior approach is more common for cervical spine, universal access site has not been defined in literature. We suggest that minimal decompression produces desirable effects with no need for fusion and preserving adequate stability of spinal complex.

Perioperative Complications of Laminoplasty in Degenerative Cervical Myelopathy -A Comparative Study Between Ossification of Posterior Longitudinal Ligament and Cervical Spondylotic Myelopathy Using a Nationwide Inpatient Database

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Laminoplasty (LAMP) is one of the effective methods to successfully achieve surgical decompression in patients with degenerative cervical myelopathy (DCM). However, little evidence exists regarding the perioperative complications in LAMP for patients with ossification of the longitudinal ligament (OPLL) compared with cervical spondylotic myelopathy (CSM). We aimed to investigate the perioperative complication rates and medical costs of DCM, including OPLL and CSM patients who underwent LAMP using a large national inpatient database.

METHODS

This study identified patients who underwent LAMP for OPLL and CSM from 2010 to 2016 using the Japanese Diagnosis Procedure Combination database. We compared the incidence of perioperative complications (systemic and local), reoperation rates, medical costs during hospitalization, and mortality were between the OPLL and CSM groups after propensity score matching.

RESULTS

This study included 22,714 patients (OPLL: 7485 patients, CSM: 15,229 patients). Consequently, 7169 pairs were matched. More perioperative systemic complications were detected in the OPLL group (one complication: 9.1% vs 7.7%; P = .002), especially for pneumonia (.5% vs .2%; P = .001) and dysphagia (.5% vs .2%; P = .004). The local complication rate was also higher in the OPLL group (paralysis: 1.1% vs .6%, P = .006; spinal fluid leakage: .4% vs .1%, P = .002). The hospitalization costs were approximately $2300 higher ($19,024 vs $16,770; P < .001) in the OPLL group.

CONCLUSIONS

More perioperative complications and higher medical costs were noted in patients with OPLL than in patients with CSM who underwent LAMP.

How cervical curvature changes after ACAF and ACDF: a radiological retrospective study

To assess changes in cervical curvature and demonstrate the feasibility of using ACAF technology to restore lordosis, imaging data from patients undergoing multilevel ACAF and ACDF surgeries were retrospectively analyzed. Forty-seven patients receiving multilevel ACAF and ACDF were included in the study. Total cervical curvature and anterior, middle, and posterior column curvature, spinal canal diameter, cervical range of motion, and surgical complications were measured and analyzed by non-parametric or chi-square tests before and after surgery. The Spearman correlation between imaging data was analyzed. Compared with ACDF, the operation time of the ACAF group was longer, the cervical motion was larger, the median and change value of the middle column curvature was larger, and the change value of the posterior column curvature was smaller (P < 0.05). The postoperative differences in cervical lordosis angle, vertebral canal diameter, and middle and posterior column curvature in the ACAF group were significantly greater than those in the ACDF group (p = 0.015). The expansion of vertebral canal diameter was significantly correlated with the difference in curvature between the middle and posterior columns (r = 0.523, P < 0.01), and the curvature of the anterior column was correlated with that of the middle and posterior columns (P < 0.05). The curvature change of the anterior column is closely related to the curvature change of the middle column and the posterior column. Compared with ACDF, ACAF expands the diameter and volume of the spinal canal by increasing the curvature of the middle column and reducing the anterior movement of the posterior column.

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.

Long-Term Survivorship of Cervical Spine Procedures; A Survivorship Meta-Analysis and Meta-Regression

STUDY DESIGN

Systematic Review.

OBJECTIVES

To conduct a meta-analysis on the survivorship of commonly performed cervical spine procedures to develop survival function curves for (i) second surgery at any cervical level, and (ii) adjacent level surgery.

METHODS

A systematic review of was conducted following PRISMA guidelines. Articles with cohorts of greater than 20 patients followed for a minimum of 36 months and with available survival data were included. Procedures included were anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (ADR), laminoplasty (LAMP), and posterior laminectomy and fusion (PDIF). Reconstructed individual patient data were pooled across studies using parametric Bayesian survival meta-regression.

RESULTS

Of 1829 initial titles, 16 citations were included for analysis. 73 811 patients were included in the second surgery analysis and 2858 patients in the adjacent level surgery analysis. We fit a Log normal accelerated failure time model to the second surgery data and a Gompertz proportional hazards model to the adjacent level surgery data. Relative to ACDF, the risk of second surgery was higher with ADR and PDIF with acceleration factors 1.73 (95% CrI: 1.04, 2.80) and 1.35 (95% CrI: 1.25, 1.46) respectively. Relative to ACDF, the risk of second surgery was lower with LAMP with deceleration factor .06 (95% CrI: .05, .07). ADR decreased the risk of adjacent level surgery with hazard ratio .43 (95% CrI: .33, .55).

CONCLUSIONS

In cases of clinical equipoise between fusion procedures, our analysis suggests superior survivorship with anterior procedures. For all procedures, laminoplasty demonstrated superior survivorship.

Comparison of the outcome after anterior cervical ossified posterior longitudinal ligament en bloc resection versus posterior total laminectomy and fusion in patients with ossification of the cervical posterior longitudinal ligament: a prospective randomized controlled trial

The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition. Between July 2017 and July 2019, 40 patients with cervical OPLL were equally randomized to undergo surgery with an ACOE or a PTLF. The clinical and radiological results were compared between the two groups. The Japanese Orthopaedic Association (JOA) score and recovery rate in the ACOE group were significantly higher than those in the PTLF group during two years postoperatively, provided that the canal occupying ratio (COR) was > 50%, or the K-line was negative. There was no significant difference in JOA scores and rate of recovery between the two groups in those in whom the COR was < 50%, or the K-line was positive. There was no significant difference in the Cobb angle between C2 and C7, sagittal vertical axis, cervical range of motion (ROM), and complications between the two groups. Compared with PTLF, ACOE is a preferred surgical approach for the surgical management of patients with cervical OPLL in that it offers a better therapeutic outcome when the COR is > 50%, or the K-line is negative, and it also preserves better cervical curvature and sagittal balance. The prognosis of ACOE is similar to that of PTLE when the COR is < 50%, or the K-line is positive.

The surgical strategy for multilevel massive ossification of the posterior longitudinal ligaments

Purpose

Creating enough decompression, favorable outcome, less complication, and maintain adequate lordosis and stability in the patients with cervical myelopathy due to multilevel massive ossification of the posterior longitudinal ligament (OPLL) still poses a challenge for surgeons. The aim of our study is to retrospectively evaluate our patients and try to seek a better surgical strategy.

Methods

Between 2015 and 2019, 55 consecutive patients with multilevel massive OPLL underwent surgical treatment. Among these, 40 patients were treated with cervical laminectomy and then anterior decompression, fusion, and fixation (ADF), which was defined as group 1, and 15 patients were treated with cervical laminectomy and fixation simultaneously, which was defined as group 2. The patient's radiographic characteristics and postoperative outcomes were evaluated.

Results

Better postoperative cervical sagittal lordosis and less long-term axial pain was achieved in group 1 (p < 0.001), though the functional outcome had no significant difference. In the multivariable analysis, anterior fixation accounts for independent factors for better cervical sagittal alignment (p < 0.001). No complications directly associated with cervical laminectomy were observed.

Conclusion

In patients with cervical multilevel massive OPLL, laminectomy at compression level and then ADF depended on the severity and range of compression, but corpectomy of not more than two vertebral bodies is suggested, except K-line (+) and long-segment massive OPLL majorly involving the C2 and posterior laminectomy above and below the OPLL-affected levels with posterior fixation simultaneously.

Factors affecting titanium mesh cage subsidence in single-level anterior cervical corpectomy and fusion for ossification of the posterior longitudinal ligament

PURPOSE

To analyze risk factors of titanium mesh cage (TMC) subsidence in single-level anterior cervical corpectomy and fusion (ACCF) for cervical ossification of the posterior longitudinal ligament (OPLL).

METHODS

TMC subsidence is defined as the reduction of the adjacent vertebral bodies by ≥ 2 mm. Patients with cervical OPLL who were treated with single-level ACCF between January 2019 and May 2021 were retrospectively analyzed in two groups: patients with TMC subsidence as Group S and patients with no TMC subsidence as Group N during the one-year follow-up period. The degree of distraction of surgical segment and correction of the cervical curvature was measured to analyze their relationship with TMC subsidence.

RESULTS

A total of 128 patients were included in Group S, and 138 patients were included in Group N. There was no significant difference in patient demographics and complications between the two groups. The degree of distraction in Group S was significantly higher than that in Group N (11.4% ± 7.6% vs. 4.7% ± 9.7%, P < 0.01). The change of C2 to C7 Cobb angle (α) in Group S was significantly greater than that in Group N (5.7 ± 2.7 vs. 1.4 ± 4.7, P < 0.01), and the change of interspinous process distance (SPD) in Group S was also significantly greater than that in Group N (7.0 ± 4.2 vs. 4.1 ± 2.7, P < 0.01). The JOA score and JOA recovery rate were not statistically different between the two groups.

CONCLUSIONS

Intraoperative selection of overlength TMC in single-level ACCF for OPLL, over-distraction and excessive correction of the cervical curvature may cause TMC subsidence after surgery. No significant impact of TMC subsidence on the surgical outcome was observed during the 1-year follow-up period.

The effect of K-line classification in different cervical dynamic position on surgical outcomes in patients with ossification of the posterior longitudinal ligament after anterior controllable antedisplacement and fusion

Purpose

To investigate whether the K-line classification in different cervical dynamic position of patients with Ossification of the Posterior Longitudinal Ligament (OPLL) affects clinical outcome after Anterior Controllable Antedisplacement and Fusion (ACAF) surgery.

Methods

A total of 93 patients who suffered from cervical spondylosis caused by OPLL underwent ACAF surgery between June 2015 and December 2017 in a single institution. Neutral, neck-flexed and neck-extended cervical radiographs were obtained from every patient. Subsequently they were classified into K-line (+) and K-line (−) with reference to the K-line classification criteria. Clinical outcomes were assessed by the JOA score, improvement rate (IR) and visual analogue scale (VAS). Radiological assessment included Cobb angle and occupation ratio (OR) of OPLL. Correlations between the long-term surgical outcomes and classification of K-line in different dynamic position were analyzed by one-way analysis of variance.

Results

Significant improvements were shown in all postoperative clinical and radiographic assessments (P < 0.05). There were no differences in IR, Cobb angle and VAS among flexion K-line (−), flexion K-line (+), extension K-line (−) and extension K-line (+) at the 2-year follow-up (P > 0.05). However, the OR of extension K-line (−) (16.13% ± 11.58%) was higher than that of extension K-line (+) (9.00% ± 10.27%) and flexion K-line (+) subgroup (9.47% ± 9.97%) (P < 0.05).

Conclusion

The ACAF procedure has shown satisfactory surgical outcomes in various K-line classifications in different dynamic position.

Ossification of the Posterior Longitudinal Ligament: Pathophysiology, Diagnosis, and Management

Ossification of the posterior longitudinal ligament (OPLL) occurs as heterotopic bone forms in the posterior longitudinal ligament, resulting in neural compression, myelopathy, and radiculopathy. OPLL is most commonly observed in East Asian populations, with prevalence rates of 1.9% to 4.3% reported in Japan. OPLL rates are lower in North American and European patients, with reported prevalence of 0.1% to 1.7%. Patients typically develop symptoms due to OPLL in their cervical spines. The etiology of OPLL is multifactorial, including genetic, metabolic, and anatomic factors. Asymptomatic or symptomatic patients with OPLL can be managed nonsurgically, whereas patients with neurologic symptoms may require surgical decompression from an anterior, posterior, or combined approach. Surgical treatment can provide notable improvement in neurologic function. Surgical decision making accounts for multiple factors, including patient comorbidities, neurologic status, disease morphology, radiographic findings, and procedure complication profiles. In this study, we review OPLL epidemiology and pathophysiology, clinical features, radiographic evaluation, management, and complications.

Perioperative Complications of Anterior Decompression with Fusion in Degenerative Cervical Myelopathy-A Comparative Study between Ossification of Posterior Longitudinal Ligament and Cervical Spondylotic Myelopathy Using a Nationwide Inpatient Database

For ossification of the posterior longitudinal ligament (OPLL) and cervical spondylotic myelopathy (CSM), anterior decompression with fusion (ADF) can accurately achieve spinal decompression. However, the difference in perioperative complications in ADF between OPLL and CSM is poorly described. This study aimed to investigate the perioperative complication rates of patients with degenerative cervical myelopathy undergoing ADF, represented by OPLL and CSM, using a large national inpatient database. In the OPLL and CSM groups, postoperative complication (systemic and local) rates, reoperation rates, medical costs during hospitalization, and mortality after propensity score matching were compared. After matching, 1197 matched pairs were made. The incidence of total systemic complications was similar between both groups (OPLL, 12.4%; CSM, 12.2%). In the OPLL group, more perioperative local complications (cerebrospinal fluid leakage: CSFL, [OPLL, 2.7%; CSM, 0.3%] and surgical site infection: SSI [OPLL, 2.1%; CSM, 0.9%]) were detected, and the hospitalization cost was approximately $3200 higher than that in the CSM group. Moreover, medical costs were significantly higher in patients who experienced complications in both OPLL and CSM. The frequency of perioperative complications of OPLL and CSM in ADF was detailed using large real-world data. Compared to CSM, OPLL had more perioperative complications such as CSFL and SSI, and higher medical costs. Regardless of the disease, medical costs were significantly increased when perioperative complications occurred.

ACDF and posterior spinal fusion revision for posterior nonunion with deformity, myelopathy, and osteoporosis in an 87-year-old: A case report and literature review

Introduction

Cervical spondylotic myelopathy (CSM) is a spinal degenerative disorder that can ultimately lead to compression of the vertebral column with neurological sequelae. Although CSM is the most common spine pathology in the elderly American population, it remains a challenging disorder to treat among older patients.

Case presentation

We report an 86 year old female patient with CSM with a history of posterior cervical fusion attempt on C3-C6 that progressed to C3-C6 nonunion with loose instrumentation. The patient had severe osteoporosis. With these indications, the patient underwent a combined anterior-posterior decompression and fusion (CAPDF) consisting of anterior cervical discectomy and fusion (ACDF) of the C3-C5, corpectomy of C6 and C7 with off FDA label use of polymethyl methacrylate augmentation (PMMA) fixation of T1 screws anteriorly for C3-T1 plate fixation and second stage instrumented posterior spinal fusion (PSF) of C3-T3. The patient had a successful fusion and reduction of her cervical spine pain with preservation of her neurological status.

Discussion

We report this case of multi-stage combined anterior and posterior fusion as a corrective measure for pseudarthrosis of a prior posterior cervical spinal fusion attempt.

Conclusion

In the event of posterior spinal fusion instrumentation failure in patients with severe osteoporosis, combined multi-stage anterior-posterior fusion is a viable corrective intervention in octogenarians. This case also illustrated the utility of using PMMA for anterior cervical plate and screw stabilization in osteoporotic bone. The authors are not aware of the prior use of PMMA for screw fixation augmentation in the anterior cervical spine.

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Combined anterior-posterior cervical fusion for cervical spondylotic myelopathy and pseudarthrosis of prior intended fusion.

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Polymethylmethacrylate (PMMA) demonstrated as safe and effective for screw purchase augmentation in anterior cervical spine

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Multi stage spinal fusion to limit prolonged one-stage anesthesia identified to be safe and effective for this patient

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Management of cervical fusion pseudarthrosis in the setting of osteoporosis in the elderly

An open-label randomized multi-Centre study to evaluate anterior controllable Antedisplacement and fusion versus posterior Laminoplasty in patients with cervical ossification of the posterior longitudinal ligament: study design and analysis plan (STAR)

Background

In treating patients with cervical ossification of the posterior longitudinal ligament (COPLL), a novel surgery technique - anterior controllable antedisplacement and fusion (ACAF) suggested promising clinical benefits in recent exploratory studies.

Methods

This is a multicentre, randomized, open-label, parallel-group, active controlled trial that will compare the clinical benefits of ACAF versus conventional posterior laminoplasty (LAMP) in severe COPLL patients. A total of 164 patients will be enrolled and randomized in a 1:1 ratio to either ACAF or LAMP group. The primary efficacy measure is cervical- Japanese Orthopaedic Association (C-JOA) recovery rate at 12 months post operation, which is to be derived by Hirabayashi’s method from JOA data (range, 0 [worst] to 17 [normal condition]). Other important secondary efficacy endpoints include visual analogue scale (VAS) pain score (range, 0 [no pain] to 10 [most severe]), 10-item neck disability index (NDI, a total range of 0 to 50 points, the highest index the worst) and 6-level Nurick disability grade (range, 0 [mild] to 5 [severe]). Safety endpoints including adverse events, perioperative complications, and adverse events of special interest will also be assessed in this study. Full analysis set for baseline and efficacy data analyses according to the intention-to-treat principle will be established as the primary analysis population. Analysis of covariance (ANCOVA) will be used to analyze the C-JOA recovery rate, with random stratification factors (if appropriate) and the treatment group as fixed factors, and the baseline level of C-JOA score as covariate.

Discussion

This study is designed to demonstrate the clinical benefits of ACAF as compared to conventional LAMP in COPLL patients. It will provide clinical evidence that the novel surgery technique – ACAF might be more favorable in treating patients with severe cervical ossification of the posterior longitudinal ligament. (Words: 290).

Trial registration

ClinicalTrials.gov number, NCT04968028.

Pattern and Rate of Functional Recovery After Surgery for Cervical Spondylotic Myelopathy: Egyptian Prospective Study

OBJECTIVE

To study pattern and rate of neurological functional recovery after surgery for cervical spondylotic myelopathy (CSM).

METHODS

This prospective study comprised 25 patients with CSM who underwent surgical decompression at our institution. Upper limb, lower limb, and sphincter functions were assessed using the modified Japanese Orthopaedic Association score (mJOA). Assessment was done before the operation and at 1 month, 3 months, and 1 year after surgery.

RESULTS

The mJOA score did not significantly increase at 1 month after surgery (P = 0.051); however, increase in mJOA score was statistically significant at 3 and 1 year after surgery (P < 0.001 and P < 0.001, respectively). Upper limb motor dysfunction improved in 65% of patients, lower limb motor dysfunction improved in 52% of patients, upper limb sensory dysfunction improved in 48% of patients, and sphincter dysfunction improved in 14.2% of patients. There was a significant positive correlation between preoperative and postoperative mJOA score at 1 month, 3 months, and 1 year after surgery.

CONCLUSIONS

Minimal improvement occurred in the first month after CSM surgery to reach a peak at 3 months after surgery and steady improvement up to 1 year after surgery. Upper limbs recovered better and earlier than lower limbs and sphincter function. Preoperative severity of CSM is one of the main predictors of postoperative neurological outcome.