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Kim CS, Kim H, Kim S, Lee JH, Jeong K, Lee HS, Kim YD. Prevalence of and factors associated with stenotic thoracic ligamentum flavum hypertrophy. Reg Anesth Pain Med 2024; 49:326-331. [PMID: 37507223 DOI: 10.1136/rapm-2023-104692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Stenotic thoracic ligamentum flavum hypertrophy can cause leg and/or low back pain similar to that caused by lumbar spinal stenosis. However, the thoracic spine may occasionally be overlooked in patients with leg and/or low back pain. An accurate understanding of the prevalence of stenotic thoracic ligamentum flavum hypertrophy and its associated factors is necessary. METHODS In this prevalence study, we reviewed whole-spine MRI scans of patients who visited the pain clinic complaining of leg and/or low back pain between 2010 and 2019. We analyzed the overall prevalence and prevalence according to the age group, sex, grade of lumbar disc degeneration, and thoracic level. In addition, we identified factors independently associated with stenotic thoracic ligamentum flavum hypertrophy occurrence. RESULTS Among 1896 patients, the overall prevalence of stenotic thoracic ligamentum flavum hypertrophy was 9.8% (185/1896), with the highest prevalence observed in the ≥80-year-old age group among all age groups (15.9%, 14/88). The region with the highest prevalence was the T10/11 level (3.0%, 57/1896). Multivariable logistic regression analysis revealed that when compared with the <50-year-old age group, all other age groups were significantly associated with stenotic thoracic ligamentum flavum hypertrophy (p<0.01). In addition, grade 5 of lumbar disc degeneration was significantly associated with stenotic thoracic ligamentum flavum hypertrophy (p=0.03). CONCLUSIONS Given the possibility for missed stenotic thoracic ligamentum flavum hypertrophy to potentially result in neurological complications, extending lumbar spine MRI covering the lower thoracic region may be considered for patients over 50 years of age with suspected severe lumbar disc degeneration.
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Affiliation(s)
- Chan-Sik Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyungtae Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sehee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ju Hwan Lee
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Wonkwang University Hospital, Iksan, Republic of Korea
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Republic of Korea
- Wonkwang Institute of Science, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Koun Jeong
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyun Seung Lee
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Yeon-Dong Kim
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Wonkwang University Hospital, Iksan, Republic of Korea
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Republic of Korea
- Wonkwang Institute of Science, Wonkwang University School of Medicine, Iksan, Republic of Korea
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Houten JK, Spirollari E, Ng C, Greisman J, Vaserman G, Dominguez JF, Kinon MD, Betchen SA, Schwartz AY. Distinctive Characteristics of Thoracolumbar Junction Region Stenosis. Clin Spine Surg 2024; 37:E52-E64. [PMID: 37735761 DOI: 10.1097/bsd.0000000000001539] [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: 03/15/2023] [Accepted: 08/10/2023] [Indexed: 09/23/2023]
Abstract
STUDY DESIGN Retrospective case series and systemic literature meta-analysis. BACKGROUND Thoracolumbar junction region stenosis produces spinal cord compression just above the conus and may manifest with symptoms that are not typical of either thoracic myelopathy or neurogenic claudication from lumbar stenosis. OBJECTIVE As few studies describe its specific pattern of presenting symptoms and neurological deficits, this investigation was designed to improve understanding of this pathology. METHODS A retrospective review assessed surgically treated cases of T10-L1 degenerative stenosis. Clinical outcomes were evaluated with the thoracic Japanese Orthopedic Association score. In addition, a systematic review and meta-analysis was performed in accordance with guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). RESULTS Of 1069 patients undergoing laminectomy at 1477 levels, 31 patients (16M/15F) were treated at T10-L1 a mean age 64.4 (SD=11.8). Patients complained of lower extremity numbness in 29/31 (94%), urinary dysfunction 11/31 (35%), and back pain 11/31 (35%). All complained about gait difficulty and objective motor deficits were detected in 24 of 31 (77%). Weakness was most often seen in foot dorsiflexion 22/31 (71%). Deep tendon reflexes were increased in 10 (32%), decreased in 11 (35%), and normal 10 (32%); the Babinski sign was present 8/31 (26%). Mean thoracic Japanese Orthopedic Association scores improved from 6.4 (SD=1.8) to 8.4 (SD=1.8) ( P <0.00001). Gait subjectively improved in 27/31 (87%) numbness improved in 26/30 (87%); but urinary function improved in only 4/11 (45%). CONCLUSIONS Thoracolumbar junction stenosis produces distinctive neurological findings characterized by lower extremity numbness, weakness particularly in foot dorsiflexion, urinary dysfunction, and inconsistent reflex changes, a neurological pattern stemming from epiconus level compression and the myelomeres for the L5 roots. Surgery results in significant clinical improvement, with numbness and gait improving more than urinary dysfunction. Many patients with thoracolumbar junction stenosis are initially misdiagnosed as being symptomatic from lumbar stenosis, thus delaying definitive surgery.
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Affiliation(s)
- John K Houten
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Eris Spirollari
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla
| | - Christina Ng
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla
| | - Jacob Greisman
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla
| | - Grigori Vaserman
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla
| | - Merritt D Kinon
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla
| | - Simone A Betchen
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, NY
| | - Amit Y Schwartz
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, NY
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Fujimoto K, Funaba M, Suzuki H, Nishida N, Ikeda H, Ichihara Y, Imajo Y, Sakai T. Transcranial Magnetic Stimulation in the Diagnosis of Compressive Myelopathy at the Thoracolumbar Junction. J Clin Neurophysiol 2024:00004691-990000000-00120. [PMID: 38194632 DOI: 10.1097/wnp.0000000000001063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
PURPOSE The disc level in the thoracolumbar junction at which measurement of the central motor conduction time in the lower limbs (CMCT-LL) is useful for a diagnosis remains unclear. Therefore, this study investigated the spinal vertebral level at which compressive myelopathy due to ossification of the ligamentum flavum in the thoracolumbar junction is detectable using CMCT-LL. METHODS We preoperatively measured CMCT-LL in 57 patients (42 men, 15 women; aged 35-85 years) with a single ossification of the ligamentum flavum from the T10-11 to T12-L1 disc levels and in 53 healthy controls. Motor evoked potentials after transcranial magnetic stimulation, compound muscle action potentials, and F waves were recorded from the abductor hallucis. Central motor conduction time in the lower limbs was calculated as follows: Motor evoked potential latency - (compound muscle action potential latency + F latency - 1)/2 (ms). Central motor conduction time in the lower limbs was compared between patients and controls. RESULTS Compressive lesions were located at the T10 to 11 level in 27 patients, the T11 to 12 level in 28, and the T12-L1 level in 2. Central motor conduction time values in the lower limbs at the T10 to 11 level (19.9 ± 4.7 ms) and T11 to 12 level (18.1 ± 3.4 ms) were significantly longer than control values (11.8 ± 1.1 ms; P < 0.01). Central motor conduction time in the lower limbs was not calculated at the T12-L1 level because motor evoked potentials were not recorded in any patient. CONCLUSIONS We confirmed that CMCT-LL was significantly longer in patients with ossification of the ligamentum flavum at the T10 to 11 and T11 to 12 levels because the S2 segment of the spinal cord is caudal at the T12 vertebral body level. Therefore, CMCT-LL is useful for diagnosing thoracolumbar junction disorders proximal to the T12 vertebral body level.
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Affiliation(s)
- Kazuhiro Fujimoto
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
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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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Lu C, Qiu H, Huang X, Yang X, Liu D, Zhang S, Zhang Y. Meta-Analysis of Simultaneous versus Staged Decompression of Stenotic Regions in Patients with Tandem Spinal Stenosis. World Neurosurg 2023; 170:e441-e454. [PMID: 36396060 DOI: 10.1016/j.wneu.2022.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tandem spinal stenosis (TSS) refers to simultaneous spinal canal stenosis of noncontiguous regions. There is no consensus in the surgical strategies for patients with symptomatic TSS because of the confusing clinical manifestations. This meta-analysis aimed to compare the outcomes of 1-stage and 2-stage decompression of all stenotic regions (cervical and lumbar/thoracic segments) in patients with TSS. METHODS A systematic review was conducted, and a comprehensive literature search with the Japanese Orthopedic Association score, was carried out using MEDLINE, Web of Science, and PubMed databases from inception to September 13, 2022. Observational studies reporting the outcomes after 1-stage or 2-stage decompression of all symptomatic regions were included. Possible heterogeneity among studies was assessed by the Higgins I2 test, and heterogeneity was statistically investigated using the Q statistic. RESULTS Thirteen retrospective observational studies were included in this meta-analysis. Meta-analysis showed that there was no significant difference in the Japanese Orthopedic Association score improvement in patients with TSS involving either the cervical-thoracic or cervical-lumbar segments. Regarding the surgical parameters and complications, 1-stage decompression showed comparable operation time, blood loss, and major complications to 2-stage decompression in patients with cervical and lumbar TSS. In patients with cervical and thoracic TSS, 1-stage decompression had significant advantages compared with 2-stage decompression in operation time, blood loss, and major complications. CONCLUSIONS For patients with cervical and lumbar TSS, 2-stage decompression showed slight advantages in clinical outcome without exposing patients to unnecessary surgical risks. For patients with cervical and thoracic TSS, 1-stage decompression showed comparable clinical outcome, although with better operative parameters and lower complication rate than in simultaneous decompression.
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Affiliation(s)
- Changbo Lu
- Department of Orthopaedic Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi, China
| | - Haiyang Qiu
- Department of Orthopaedic Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi, China
| | - Xinyi Huang
- Department of Orthopaedic Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi, China
| | - Xiaojiang Yang
- Department of Orthopaedic Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi, China
| | - Daming Liu
- Department of Orthopaedic Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi, China
| | - Saili Zhang
- Department of Orthopaedic Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi, China
| | - Yang Zhang
- Department of Orthopaedic Surgery, Xijing Hospital, Air Force Military Medical University, Xi'an, Shaanxi, China.
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Mittal S, Ahuja K, Sudhakar PV, Ifthekar S, Yadav G, Sarkar B, Kandwal P. Simultaneous decompression of all stenotic regions versus decompression of only the most symptomatic region in patients with tandem spinal stenosis: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:561-574. [PMID: 34988710 DOI: 10.1007/s00586-021-07078-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 06/15/2021] [Accepted: 11/25/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Selection of anatomic region of spine for decompression in patients with symptomatic tandem spinal stenosis (TSS) remains a challenge due to the confusing clinical presentation as well as uncertain evidence. A systematic review and meta-analysis of observational studies were conducted to compare the outcomes between simultaneous decompression of all stenotic regions (cervical and lumbar, Group 1) and decompression of only the most symptomatic stenotic region (cervical/lumbar, Group 2) in patients with TSS. METHODS A systematic review was conducted, and a comprehensive literature search with well-established inclusion and exclusion criteria with JOA score as an outcome measure was done on PubMed, Google Scholar, and EMBASE database (till January 2021). Observational studies reporting outcomes after simultaneous decompression or only the most symptomatic region were included. NIH quality assessment tool was used to check the quality of each study, and treatment effects were calculated using Dersimonian and Laird random effects model. RESULTS Ten studies were included in the analysis out of which all were retrospective observational studies (Level 4 evidence) except one (Level 3 evidence). Overall proportional meta-analysis showed no significant difference in change in JOA scores, operative time, blood loss, total and major complications between Group 1 and Group 2. However, minor complications were significantly increased on performing decompression of both regions simultaneously (p = 0.04). On performing subgroup analysis comparing cervical surgery cohort with lumbar surgery cohort, no difference was found in change in JOA score and requirement of second-stage surgery. CONCLUSION Decompression of the most symptomatic region alone irrespective of its location has equal clinical outcomes with less complication rate than simultaneous decompression in patients with TSS.
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Affiliation(s)
| | | | - P V Sudhakar
- AIIMS Rishikesh, Rishikesh, Uttarakhand, 249203, India
| | - Syed Ifthekar
- AIIMS Rishikesh, Rishikesh, Uttarakhand, 249203, India
| | | | | | - Pankaj Kandwal
- Department of Orthopaedics, AIIMS Rishikesh, Rishikesh, Uttarakhand, 249203, India.
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Li J, Hu Z, Qian Z, Tang Z, Qiu Y, Zhu Z, Liu Z. The prognosis and recovery of major postoperative neurological deficits after corrective surgery for scoliosis : an analysis of 65 cases at a single institution. Bone Joint J 2022; 104-B:103-111. [PMID: 34969290 DOI: 10.1302/0301-620x.104b1.bjj-2021-0772.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years. METHODS A major neurological deficit was identified in 65 of 8,870 patients who underwent corrective surgery for scoliosis, including eight with complete paraplegia and 57 with incomplete paraplegia. There were 23 male and 42 female patients. Their mean age was 25.0 years (SD 16.3). The aetiology of the scoliosis was idiopathic (n = 6), congenital (n = 23), neuromuscular (n = 11), neurofibromatosis type 1 (n = 6), and others (n = 19). Neurological function was determined by the American Spinal Injury Association (ASIA) impairment scale at a mean follow-up of 45.4 months (SD 17.2). the patients were divided into those with recovery and those with no recovery according to the ASIA scale during follow-up. RESULTS The incidence of major deficit was 0.73%. At six-month follow-up, 39 patients (60%) had complete recovery and ten (15.4%) had incomplete recovery; these percentages improved to 70.8% (46) and 16.9% (11) at follow-up of two years, respectively. Eight patients showed no recovery at the final follow-up. The cause of injury was mechanical in 39 patients and ischaemic in five. For 11 patients with misplaced implants and haematoma formation, nine had complete recovery. Fisher's exact test showed a significant difference in the aetiology of the scoliosis (p = 0.007) and preoperative deficit (p = 0.016) between the recovery and non-recovery groups. A preoperative deficit was found to be significantly associated with non-recovery (odds ratio 8.5 (95% confidence interval 1.676 to 43.109); p = 0.010) in a multivariate regression model. CONCLUSION For patients with scoliosis who develop a major neurological deficit after corrective surgery, recovery (complete and incomplete) can be expected in 87.7%. The first three to six months is the time window for recovery. In patients with misplaced implants and haematoma formation, the prognosis is satisfactory with appropriate early intervention. Patients with a preoperative neurological deficit are at a significant risk of having a permanent deficit. Cite this article: Bone Joint J 2022;104-B(1):103-111.
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Affiliation(s)
- Jie Li
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zongshan Hu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhikai Qian
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Ziyang Tang
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zezhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhen Liu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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He C, Longbiao X, Zhao M, Wang L, Sharma HS. Diagnosis experience and literature review of patients with cervical, thoracic and lumbar multi-segment spinal stenosis: A case report. PROGRESS IN BRAIN RESEARCH 2021; 266:377-385. [PMID: 34689865 DOI: 10.1016/bs.pbr.2021.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The incidence of cervical, thoracic and lumbar spinal canal stenosis is low. It is difficult to identify the main focus and responsible segment, and it is also difficult to select the sequence of staging surgery. We report a patient with triple stenosis. CASE PRESENTATION In this paper, we introduced a 61-year-old female patient with cervical, thoracic and lumbar spinal canal stenosis who had previously undergone "lumbar discectomy" in the outer hospital. The postoperative effect was not good and the symptoms were poor. The diagnosis was "cervical spinal stenosis and lumbar spine surgery." The staged spinal canal decompression operation and Duhuo Jisheng Decoction (DHJSD) treatment were conducted in our hospital. After 3 months of follow-up, the functional and imaging results were satisfactory. CONCLUSION We should pay enough attention to the patients with spinal degenerative diseases who need surgery, and must pursue the unity of medical history, signs and images. In case of difficult patients, more comprehensive examination is required, and the main focus and responsible segment are determined through comprehensive analysis. The more important diseases that may exist cannot be covered up by focal lesion manifestations, so as to avoid unnecessary surgical trauma for patients. In addition, surgery combined with Chinese herbal medicine DHJSD therapy may be an effective treatment for this kind of disease.
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Affiliation(s)
- Chao He
- Department of Neurosurgery, Zhuji People' Hospital of Zhejiang Province, Zhuji Affiliated Hospital of Shaoxing University, Zhuji, Zhejiang, China
| | - Xu Longbiao
- Department of Neurosurgery, Zhuji People' Hospital of Zhejiang Province, Zhuji Affiliated Hospital of Shaoxing University, Zhuji, Zhejiang, China
| | - Ming Zhao
- Department of Neurosurgery, Zhuji People' Hospital of Zhejiang Province, Zhuji Affiliated Hospital of Shaoxing University, Zhuji, Zhejiang, China
| | - Lin Wang
- Department of Neurosurgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Hari Shanker Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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Nudelman B, Mittal A, Rosinski A, Zaborovskii N, Wu S, Kondrashov D. Whole-Spine Magnetic Resonance Imaging: A Review of Suggested Indications. JBJS Rev 2021; 9:01874474-202107000-00004. [PMID: 34257232 DOI: 10.2106/jbjs.rvw.20.00267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» The spinal column has a propensity for lesions to manifest in a multifocal manner, and identification of the lesions can be difficult. » When used to image the spine, magnetic resonance imaging (MRI) most accurately identifies the presence and location of lesions, guiding the treatment plan and preventing potentially devastating complications that are known to be associated with unidentified lesions. » Certain conditions clearly warrant evaluation with whole-spine MRI, whereas the use of whole-spine MRI with other conditions is more controversial. » We suggest whole-spine MRI when evaluating and treating any spinal infection, lumbar stenosis with upper motor neuron signs, ankylosing disorders of the spine with concern for fracture, congenital scoliosis undergoing surgical correction, and metastatic spinal tumors. » Use of whole-spine MRI in patients with idiopathic scoliosis and acute spinal trauma remains controversial.
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Affiliation(s)
- Brandon Nudelman
- San Francisco Orthopaedic Residency Program, San Francisco, California
| | - Ashish Mittal
- San Francisco Orthopaedic Residency Program, San Francisco, California
| | | | - Nikita Zaborovskii
- Spine Surgery and Oncology, R.R. Vreden Russian Research Institute of Traumatology and Orthopedics, Saint Petersburg, Russia
| | - Samuel Wu
- San Francisco Orthopaedic Residency Program, San Francisco, California
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Yamada T, Shindo S, Yoshii T, Ushio S, Kusano K, Miyake N, Arai Y, Otani K, Okawa A, Nakai O. Surgical outcomes of the thoracic ossification of ligamentum flavum: a retrospective analysis of 61 cases. BMC Musculoskelet Disord 2021; 22:7. [PMID: 33397347 PMCID: PMC7784257 DOI: 10.1186/s12891-020-03905-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/22/2020] [Indexed: 12/05/2022] Open
Abstract
Background Thoracic ossification of ligamentum flavum (T-OLF), as one of the causes of thoracic myelopathy, is often combined with other spinal disorders. Concurrent lumbar spinal canal stenosis (LCS) is often obscured by symptoms due to T-OLF, leading to difficulty in identifying the origin of these neurological findings. It is common to be misdiagnosed or delayed diagnosis due to the complicated nature. We evaluated the prevalence, distribution, and clinical characteristics of OLF, especially in patients with LCS. Methods The authors performed a retrospective analysis of the outcomes of 61 patients who underwent thoracic surgeries performed for symptomatic T-OLF. In all the patients, whole spine lesions were evaluated preoperatively. We examined the factors related to poor outcomes (the recovery rate of the Japanese Orthopedic Association score for thoracic myelopathy is less than 40%) following OLF surgeries. We compared the clinical outcomes according to whether there was concurrent LCS, and determined the optimal surgical approach. Results The occurrence of T-OLF increased with age. Forty-six cases (75.4%) were considered to be tandem T-OLF and LCS (LCS group). An advanced age, and concurrent LCS were associated with a poor outcome after the surgery. The LCS group significantly included a greater number of elderly, and more light-weighted patients with Modic change in thoracic spine and a greater sagittal vertical axis, resulting in the lower neurological recovery. Additional lumbar surgery (13cases) effectively improved both the T-JOA and L-JOA scores (from 6.5 ± 2.0 points to 8.0 ± 1.8 points, p = 0.0406, and from 14.5 ± 4.7 points to 20.7 ± 2.6 points, p = 0.001, respectively) in OLF patients with LCS. Conclusions T-OLF was highly associated with other spinal disorders. Poor outcomes in T-OLF surgery could be associated with age and concurrent LCS, and an additional surgery for another lumbar lesion significantly improved neurological findings in T-OLF patients.
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Affiliation(s)
- Tsuyoshi Yamada
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan. .,Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, 113-8510, Japan.
| | - Shigeo Shindo
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, 113-8510, Japan
| | - Shuta Ushio
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan
| | - Kazuo Kusano
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan
| | - Norihiko Miyake
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan
| | - Yoshiyasu Arai
- Department of Orthopaedic Surgery, Saiseikai Kawaguchi General Hospital, 5-11-5 Nishikawaguchi, 332-8558, Kawaguchi-city, Saitama, Japan
| | - Kazuyuki Otani
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, 113-8510, Japan
| | - Osamu Nakai
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudan- minami, Chiyoda-ku, 102-0074, Tokyo, Japan.,Department of Orthopaedic Surgery, Graduate School, Tokyo Medical and Dental University, Tokyo, 113-8510, Japan
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Diagnosis, Management, and Clinical Outcomes of Tandem Thoracic and Lumbar Stenosis: A Systematic Literature Review and Case Series. World Neurosurg 2020; 143:546-552.e1. [PMID: 32526367 DOI: 10.1016/j.wneu.2020.06.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/31/2020] [Accepted: 06/02/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND A scarcity of data has been reported on tandem thoracic lumbar stenosis, which might be related to either the rarity or underdiagnosis of the condition. We have presented a systematic review of the clinical presentation, diagnosis, and treatment patterns for patients with symptomatic tandem thoracic and lumbar stenosis. METHODS A PubMed/MEDLINE search was performed to find reports of patients with symptomatic tandem thoracic and lumbar stenosis. RESULTS The review identified 10 studies with a total of 48 patients with tandem thoracic and lumbar stenosis. Most patients (n = 41; 85%) had had tandem stenosis diagnosed at the initial investigation, with 71% of the reports citing ossification of the ligamentum flavum as a contributing etiology. A few patients (n = 7; 15%) had had thoracic lesions diagnosed after neurologic deterioration that had occurred after lumbar surgery for previously suspected isolated lumbar stenosis. Surgical management varied from isolated thoracic decompression, staged decompression, and simultaneous decompression. Most patients (n = 41; 87%) showed improved neurologic status after surgery. CONCLUSION Ossification of the ligamentum flavum might play a key role in the pathogenesis of the condition. Most patients with tandem thoracic and lumbar stenosis will show improvement after surgical decompression. Although the limited evidence available has raised concerns regarding neurologic deterioration after initial lumbar decompression in patients with coexisting thoracic stenosis, the data are insufficient to definitively determine an optimal surgical strategy. Further research is needed to identify the optimal diagnostic and management criteria for patients with symptomatic tandem thoracic and lumbar stenosis.
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Abstract
Tandem spinal stenosis (TSS) refers to simultaneous narrowing of noncontiguous regions of the spinal canal, typically the cervical and lumbar region. Symptomatic TSS may be present in more than 10% of patients presenting with spinal symptoms secondary to stenosis in any one region. Clinical presentation may present challenges because of a mixture of upper and lower motor neuron lesions that can confuse and mislead the clinician. Stenosis at another level may only be detected late, when there is failure to improve after treatment, and, if not detected, can result in either poor treatment outcomes or catastrophic complications. There is no uniform agreement in the management of TSS, and the reported surgical strategies include both simultaneous and staged approaches with each having positive and negative features. This article aims to provide the reader with details on the prevalence, evaluation, and guidance in treatment strategy for TSS.
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13
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Symptomatic tandem spinal stenosis: a clinical, diagnostic, and surgical challenge. Neurosurg Rev 2019; 43:1289-1295. [DOI: 10.1007/s10143-019-01154-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/20/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
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Stolper K, Haug JC, Christensen CT, Samsey KM, April MD. Prevalence of thoracic spine lesions masquerading as cauda equina syndrome: yield of a novel magnetic resonance imaging protocol. Intern Emerg Med 2017; 12:1259-1264. [PMID: 27815809 DOI: 10.1007/s11739-016-1565-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
Our objective was to describe the yield of actionable thoracic spine lesions for a novel magnetic resonance imaging (MRI) protocol including evaluation of the thoracic spine among patients presenting to the Emergency Department (ED) with symptoms consistent with epidural compression syndrome. Our ED and Department of Radiology together designed a novel rapid MRI protocol entailing 3D volumetric T2 weighted sequences through both the thoracic and lumbar spine obtained in the sagittal plane to assess for both lumbar and thoracic spine lesions. We recorded study outcomes for all patients undergoing this protocol or conventional lumbar MRI during May 2014-May 2015 to determine the prevalence of actionable thoracic spine lesions. We defined an actionable thoracic lesion as any pathology requiring treatment (e.g., medication, admission, surgery) not otherwise indicated on the basis of lumbar spine findings. During the study period, 112 of 124 (90.3%) of ED patients undergoing MRI evaluation for epidural compression syndrome underwent the novel protocol. The remaining patients underwent evaluation of the lumbar spine using only a conventional MRI protocol. Of the 112 patients undergoing the novel protocol, 6 (5.4%) patients had thoracic spine lesions indicating therapy not otherwise indicated by lumbar spine findings. The etiologies of these six lesions were: neoplasms (2), de-myelination (2), compression fracture (1), and degeneration due to pernicious anemia (1). Emergency providers should strongly consider the routine use of MRI protocols including thoracic spine evaluation in patients presenting to the ED with symptoms consistent with epidural compression syndrome.
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Affiliation(s)
- Katherine Stolper
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, SAMMC, MCHE-EMR, 3551 Roger Brooke Dr, JBSA, Fort Sam Houston, TX, 78234-6200, USA
| | - James Clark Haug
- Department of Radiology, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, USA
| | - Chad Todd Christensen
- Department of Radiology, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, USA
| | - Kathleen Michelle Samsey
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, SAMMC, MCHE-EMR, 3551 Roger Brooke Dr, JBSA, Fort Sam Houston, TX, 78234-6200, USA
| | - Michael David April
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, SAMMC, MCHE-EMR, 3551 Roger Brooke Dr, JBSA, Fort Sam Houston, TX, 78234-6200, USA.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an updated review of adult degenerative scoliosis (ADS). Epidemiology, classification, pathophysiology, and natural history are discussed along with a summary of commonly used outcome measures. Operative vs non-operative outcomes and new surgical techniques are discussed. RECENT FINDINGS The SRS-Schwab classification (2012) combines clinical and radiographic evaluation including overall global alignment. Current evidence regarding risk factors and efficacy of non-surgical modalities are discussed. Recent studies have reported surgical management to provide superior outcomes to non-operative modalities. New surgical techniques provide promising early data in regard to decreasing perioperative morbidity. ADS is a potentially debilitating condition that occurs with asymmetric spinal degeneration. This can produce global sagittal malalignment and central and foraminal stenosis and can lead to significant impairment often necessitating surgery. The surgeon must be aware of the perioperative risks in this population and implement appropriate age-specific alignment goals to achieve the best outcome for patients.
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Affiliation(s)
- Philip J York
- Department of Orthopaedic Surgery, University of Colorado, Aurora, CO, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, 10021, USA.
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Fujimoto K, Kanchiku T, Imajo Y, Suzuki H, Yoshida Y, Nishida N, Funaba M, Taguchi T. Neurologic findings caused by ossification of ligamentum flavum at the thoracolumbar junction. J Spinal Cord Med 2017; 40:316-320. [PMID: 26829878 PMCID: PMC5472019 DOI: 10.1080/10790268.2015.1118185] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE To evaluate neurologic findings caused by a single ossification of ligamentum fravum (OLF) and identify the level of the lumbar segment of spinal cord. DESIGN Retrospective study. METHODS Subjects were 28 patients with a single OLF at T10-11 level (15 patients), T11-12 (11), and T12-L1 (2). The tip of the conus medullaris was assessed using computed tomographic myelography or magnetic resonance imaging. Neurologic evaluations were performed for patellar tendon reflex (PTR), sensory disturbance, and motor weakness. RESULTS The tip of the conus medullaris was located at the L1 vertebral body level. At the T10-11 level, all patients showed hyperreflexia of PTR. Sensory disturbance was observed for L1 dermatome and weakness of the iliopsoas was noted. At the T11-12 level, 8 of 11 patients didn't show hyperreflexia of PTR. Sensory disturbance was observed for L5 dermatome and weakness of the tibialis anterior was noted. At the T12-L1 level, all patients showed normal reflex of PTR, sensory disturbance of L5 dermatome, and weakness of the tibialis anterior. CONCLUSION With regard to the relationship between PTR and OLF level, all patients at the T10-11 level showed involvement of the L3 segment of spinal cord proximally. On the other hand, most patients at the T11-12 level showed involvement of the L4 segment of spinal cord distally. From all neurologic findings, we confirmed the presence of the L4 segment of spinal cord from the lower third of T11 vertebral body to the T11-12 intervertebral disc level.
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Affiliation(s)
- Kazuhiro Fujimoto
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
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Abstract
The treatment of adult degenerative scoliosis begins in the outpatient setting when evaluating a patient both radiographically. Assessing the flexibility of the deformity is essential in determining what techniques will be required to achieve the goals of correction. Ultimately the surgeon's comfort and experience and the patient's medical risk stratification determine the strategy needed to address either a focal pathology or ultimate deformity correction.
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Stolper K, Hanlin ER, April MD, Ritter JL, Hunter CJ, Samsey K, Maddry JK. Thoracic spinal cord compression masquerading as cauda equina syndrome. Am J Emerg Med 2015; 34:756.e3-5. [PMID: 26346050 DOI: 10.1016/j.ajem.2015.07.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 07/25/2015] [Indexed: 11/25/2022] Open
Affiliation(s)
- Katherine Stolper
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium; Department of Radiology, San Antonio Uniformed Services Health Education Consortium
| | - Erin R Hanlin
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium; Department of Radiology, San Antonio Uniformed Services Health Education Consortium
| | - Michael D April
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium; Department of Radiology, San Antonio Uniformed Services Health Education Consortium
| | - John L Ritter
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium; Department of Radiology, San Antonio Uniformed Services Health Education Consortium
| | - Curtis J Hunter
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium; Department of Radiology, San Antonio Uniformed Services Health Education Consortium
| | - Kathleen Samsey
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium; Department of Radiology, San Antonio Uniformed Services Health Education Consortium
| | - Joseph K Maddry
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium; Department of Radiology, San Antonio Uniformed Services Health Education Consortium
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19
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Li WJ, Guo SG, Sun ZJ, Zhao Y. Multilevel thoracic ossification of ligamentum flavum coexisted with/without lumbar spinal stenosis: staged surgical strategy and clinical outcomes. BMC Musculoskelet Disord 2015; 16:206. [PMID: 26286579 PMCID: PMC4545777 DOI: 10.1186/s12891-015-0672-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 08/10/2015] [Indexed: 11/29/2022] Open
Abstract
Background Thoracic ossification of ligamentum flavum (TOLF) is a progressively disabling disease. Isolated or continuous TOLF has been frequently reported in literature, however there are very few reports of multilevel or non-continuous TOLF. The purpose of the study was to discuss the surgical strategy of multilevel TOLF and evaluate safety and efficacy of a two-stage operation regimen. Methods From October 2007 to May 2014, eleven patients (4 males, 7 females) that underwent two-stage surgery for multilevel spinal stenosis were retrospectively reviewed. The follow-up period lasted at least 12 months. Demographic data, radiological findings as well as operative data were collected. Postoperative functional outcomes evaluated by the modified Japanese Orthopedic Association score (mJOA) and complications were analyzed. Results The patients ranged in age from 30 to 65 years (average, 50.2 ± 11.8 years), and comprised 4 men and 7 women. All patients exhibited significant improvements in neurological deficits. The mJOA score improved from a mean of 3.5 ± 2.2 preoperatively to 4.6 ± 2.3 before second-stage surgery and to 7.5 ± 2.2 at final follow-up. The improvement was statistically significant in the average mJOA improvement rate at final follow-up. No staging-related complications were noted in this study. Conclusions Staged surgery can effectively achieve neurological functional recovery in patients with multi-segment spinal stenosis in thoracic and lumbar regions, with favorable efficacy and safety. Yet, slight neurological deterioration was observed during the intervals of these two index surgeries.
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Affiliation(s)
- Wen-jing Li
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dong Cheng District Shuai Fu Yuan No.1, Beijing, 100730, China.
| | - Shi-gong Guo
- Department of Trauma & Orthopaedic Surgery, Lister Hospital, Stevenage, UK.
| | - Zhi-jian Sun
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dong Cheng District Shuai Fu Yuan No.1, Beijing, 100730, China.
| | - Yu Zhao
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Dong Cheng District Shuai Fu Yuan No.1, Beijing, 100730, China.
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Uehara M, Tsutsumimoto T, Yui M, Ohta H, Ohba H, Misawa H. Single-stage surgery for compressive thoracic myelopathy associated with compressive cervical myelopathy and/or lumbar spinal canal stenosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015. [DOI: 10.1007/s00586-015-4133-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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