Risk factors for poor outcome of cervical laminoplasty for cervical spondylotic myelopathy in patients with diabetes

Application of Short T1 Inversion Recovery Sequence in Increased Signal Intensity Following Cervical Spondylotic Myelopathy

OBJECTIVES

To compare magnetic resonance (MR) short T1 inversion recovery (STIR) sequence with MR T2-weighted (T2W) sequence for detecting increased signal intensity (ISI) and assessing outcomes of ISI in cervical spondylotic myelopathy (CSM).

METHODS

Data of patients with CSM who showed ISI on MR imaging and had undergone cervical spine surgery were retrospectively reviewed. STIR and T2W images were examined to assess signal intensity ratio (SIR), length and grading of the ISI, maximal spinal cord compression, canal narrowing ratio, and ligamentum flavum hypertrophy. The patients were divided into good and poor groups based on their outcomes. χ2 tests and variance analysis were used to assess intergroup differences. Univariate and multivariate logistic regression analyses were performed to identify risk factors for poor outcomes, and receiver operating characteristic curves were plotted to detect prognostic effects.

RESULTS

SIR and ISI lengths were significantly different between the STIR and T2 images. In the univariate logistic regression analysis, age, diabetes, SIRT2, SIRSTIR, and ISISTIR grading were significant factors. Accordingly, in the multivariate logistic regression analysis, age, diabetes, SIRT2, and SIRSTIR were included in the model. Among patients with diabetes, we observed a significant difference between SIRT2 and SIRSTIR.

CONCLUSIONS

The STIR sequence demonstrated superior capability to the T2W sequence in detecting ISI; however, there was no obvious difference in predicted outcomes. STIR sequence has a better prognostic value than T2W sequence in patients with diabetes who have CSM. ISI grading based on the STIR sequence may be a clinically valuable indicator.

The significance of metabolic disease in degenerative cervical myelopathy: a systematic review

Introduction

Degenerative cervical myelopathy (DCM) is a form of chronic spinal cord injury, with a natural history of potential for progression over time. Whilst driven by mechanical stress on the spinal cord from degenerative and congenital pathology, the neurological phenotype of DCM is likely to be modified by multiple systemic factors. The role of metabolic factors is therefore of interest, particularly given that ischaemia is considered a key pathological mechanism of spinal cord injury. The objective was therefore to synthesise current evidence on the effect of metabolism on DCM susceptibility, severity, and surgical outcomes.

Methods

A systematic review in MEDLINE and Embase was conducted following PRISMA guidelines. Full-text papers in English, with a focus on DCM and metabolism, including diabetes, cardiovascular disease, anaemia, and lipid profile, were eligible for inclusion. Risk of methodological bias was assessed using the Joanna Briggs Institute (JBI) critical assessment tools. Quality assessments were performed using the GRADE assessment tool. Patient demographics, metabolic factors and the relationships between metabolism and spinal cord disease, spinal column disease and post-operative outcomes were assessed.

Results

In total, 8,523 papers were identified, of which 57 met criteria for inclusion in the final analysis. A total of 91% (52/57) of included papers assessed the effects of diabetes in relation to DCM, of which 85% (44/52) reported an association with poor surgical outcomes; 42% of papers (24/57) discussed the association between cardiovascular health and DCM, of which 88% (21/24) reported a significant association. Overall, DCM patients with diabetes or cardiovascular disease experienced greater perioperative morbidity and poorer neurological recovery. They were also more likely to have comorbidities such as obesity and hyperlipidaemia.

Conclusion

Metabolic factors appear to be associated with surgical outcomes in DCM. However, evidence for a more specific role in DCM susceptibility and severity is uncertain. The pathophysiology and natural history of DCM are critical research priorities; the role of metabolism is therefore a key area for future research focus.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021268814.

The effect of preoperative different dexamethasone regimens on postoperative glycemic control in patients with type 2 diabetes mellitus undergoing total joint arthroplasty: a retrospective cohort study

BACKGROUND

Concerns have been raised regarding the impact of preoperative intravenous dexamethasone on postoperative glycemic control in diabetic patients undergoing total joint arthroplasty (TJA). This study aimed to determine relationships between preoperative different dexamethasone regimens and postoperative fasting blood glucose (FBG), as well as to identify risk factors for postoperative FBG ≥ 200 mg/dl in diabetic patients undergoing TJA.

METHODS

This retrospective study included 1216 diabetic patients undergoing TJA and categorized into group A (dexamethasone = 0 mg), group B (dexamethasone = 5 mg), and group C (dexamethasone = 10 mg). All dexamethasone was administered before skin incision. FBG levels were monitored until postoperative day (POD) 3. Analyses were conducted for periprosthetic joint infection (PJI) and wound complications during 90 days postoperatively. And the risk factors for postoperative FBG ≥ 200 mg/dl were identified.

RESULTS

Preoperative dexamethasone administration resulted in a transiently higher FBG on POD 0 and POD 1 (all P < 0.001). However, no differences were observed on POD 2 (P = 0.583) and POD 3 (P = 0.131) among three groups. While preoperative dexamethasone led to an increase in postoperative mean FBG and postoperative maximum FBG (all P < 0.001), no differences were found in wound complications (P = 0.548) and PJI (P = 1.000). Increased HbA1c and preoperative high FBG, but not preoperative dexamethasone, were identified as risk factors for postoperative FBG ≥ 200 mg/dl. Preoperative HbA1c level of ≥ 7.15% was associated with an elevated risk of postoperative FBG ≥ 200 mg/dl.

CONCLUSIONS

Although preoperative intravenous administration of 5 mg or 10 mg dexamethasone in diabetic patients showed transient effects on postoperative FBG after TJA, no differences were found in the rates of PJI and wound complications during 90 days postoperatively. Notably, patients with a preoperative HbA1c level of ≥ 7.15% and elevated preoperative FBG may encountered postoperative FBG ≥ 200 mg/dl.

Classification and prognostic factors of patients with cervical spondylotic myelopathy after surgical treatment: a cluster analysis

Identifying potential prognostic factors of CSM patients could improve doctors' clinical decision-making ability. The study retrospectively collected the baseline data of population characteristics, clinical symptoms, physical examination, neurological function and quality of life scores of patients with CSM based on the clinical big data research platform. The modified Japanese Orthopedic Association (mJOA) score and SF-36 score from the short-term follow-up data were entered into the cluster analysis to characterize postoperative residual symptoms and quality of life. Four clusters were yielded representing different patterns of residual symptoms and quality of patients' life. Patients in cluster 2 (mJOA RR 55.8%) and cluster 4 (mJOA RR 55.8%) were substantially improved and had better quality of life. The influencing factors for the better prognosis of patients in cluster 2 were young age (50.1 ± 11.8), low incidence of disabling claudication (5.0%) and pathological signs (63.0%), and good preoperative SF36-physiological function score (73.1 ± 24.0) and mJOA socre (13.7 ± 2.8); and in cluster 4 the main influencing factor was low incidence of neck and shoulder pain (11.7%). We preliminarily verified the reliability of the clustering results with the long-term follow-up data and identified the preoperative features that were helpful to predict the prognosis of the patients. This study provided reference and research basis for further study with a larger sample data, extracting more patient features, selecting more follow-up nodes, and improving clustering algorithm.

Diagnostic and prognostic significance of preoperative evoked potential tests in degenerative cervical myelopathy

BACKGROUND CONTEXT

Decompression surgery is a treatment option for patients with degenerative cervical myelopathy (DCM). Surgical decisions primarily depend on clinical symptoms and radiological examinations. The diagnostic and prognostic significance of evoked potential tests for surgical outcomes in patients with DCM has not been thoroughly examined.

PURPOSE

To identify the diagnostic and prognostic significance of preoperative evoked potential tests in patients with DCM who underwent decompression surgery.

STUDY DESIGN

This was a retrospective observational study.

PATIENT SAMPLE

One hundred two consecutive patients who underwent evoked potential tests and surgical treatment between January 2016 and December 2020 in a single spine center and had a minimum follow-up of 6 months.

OUTCOME MEASURES

Japanese Orthopedic Association (JOA) scores obtained preoperatively and 6 months after surgery.

METHODS

This study evaluated the preoperative central motor conduction time (CMCT), somatosensory evoked potentials, and Japanese Orthopedic Association (JOA) scores obtained preoperatively and 6 months after surgery.

RESULTS

Abnormal CMCT findings were observed in 94 patients (92.2%). Abnormal somatosensory evoked potentials were observed in 77 patients (75.5%). There was a statistically significant correlation between preoperative JOA score and abductor pollicis brevis (APB)-CMCT (r=-0.546, p=.001), tibialis anterior (TA)-CMCT (r=-0.517, p<.001), median nerve (MN)-SSEP (r=-0.353, p=.001), and tibial nerve (TN)-SSEP (r=-0.349, p=.003). There were significant differences in recovery rates associated with diabetes mellitus (DM), preoperative severity of myelopathy, TA-CMCT, MN-SSEP, and TN-SSEP. Stepwise multiple regression analysis showed that the major factors affecting the clinical outcomes were TN-SSEP (β=0.327, p=.004), preoperative JOA score (β=0.278, p=.012), and DM (β=0.241, p=.025).

CONCLUSIONS

Evoked potential testing is a functional diagnostic tool that can indicate the severity of myelopathic symptoms in patients with DCM. Additionally, preoperative TN-SSEP may have significant prognostic value in predicting postoperative clinical outcomes. Thus, preoperative evoked potential tests could be helpful for determining suitable surgical treatment candidates and forecasting postoperative prognosis.

Strong association of lumbar disk herniation with diabetes mellitus: a 12-year nationwide retrospective cohort study

Background

Despite reports on the association between diabetes mellitus (DM) and lumbar disk herniation (LDH), large-scale, nationwide studies exploring this relationship are lacking. We aimed to examine the profiles of DM in individuals with LDH and explore the potential mechanisms underlying the development of these disorders.

Methods

This retrospective, population-based study was conducted between 2008 and 2019 using data from the National Health Insurance (NHI) research database in Taiwan. The primary outcome was the date of initial LDH diagnosis, death, withdrawal from the NHI program, or end of the study period.

Results

In total, 2,662,930 individuals with and 16,922,546 individuals without DM were included in this study; 719,068 matched pairs were established following propensity score matching (1:1 ratio) for sex, age, comorbidities, smoking, alcohol consumption, antihyperglycemic medications, and index year. The adjusted risk for developing LDH was 2.33-fold (95% confidence interval: 2.29-2.37; P<0.001), age-stratified analysis revealed a significantly greater risk of LDH in every age group, and both males and females were approximately twice as likely to develop LDH in the DM compared with non-DM cohort. Individuals with DM and comorbidities had a significantly higher risk of developing LDH than those without, and the serial models yielded consistent results. Treatment with metformin, sulfonylureas, meglitinides, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, or alpha-glucosidase inhibitors was associated with a more than 4-fold increased risk of LDH in the DM cohort. DM was strongly associated with the long-term development of LDH; over the 12-year follow-up period, the cumulative risk of LDH was significantly higher in patients with than without DM (log-rank P<0.001).

Conclusion

DM is associated with an increased risk of LDH, and advanced DM may indicate a higher risk of LDH.

Electrophysiological evidence of diabetes' impacts on central conduction recoveries in degenerative cervical myelopathy after surgery

OBJECTIVES

To assess the impact of diabetes mellitus (DM) on the postoperative motor and somatosensory functional recoveries of degenerative cervical myelopathy (DCM) patients.

METHODS

Motor and somatosensory evoked potentials (MEP and SSEPs) and modified Japanese Orthopedic Association (mJOA) scores were recorded in 27 diabetic (DCM-DM group) and 38 non-diabetic DCM patients (DCM group) before and 1 year after surgery. The central motor (CMCT) and somatosensory (CSCT) conduction time were recorded to evaluate the conductive functions of the spinal cord.

RESULTS

The mJOA scores, CMCT and CSCT improved (t test, p < 0.05) in both of the DCM-DM and DCM groups 1 year after surgery. The mJOA recovery rate (RR) and CSCT recovery ratio were significantly worse (t test, p < 0.05) in the DCM-DM group compared to the DCM group. DM proved to be a significant independent risk factor for poor CSCT recovery (OR = 4.52, 95% CI 2.32-7.12) after adjusting for possible confounding factors. In DCM-DM group, CSCT recovery ratio was also correlated with preoperative HbA1 level (R =  - 0.55, p = 0.003). Furthermore, DM duration longer than 10 years and insulin dependence were risk factors for lower mJOA, CMCT and CSCT recoveries among all DCM-DM patients (t test, p < 0.05).

CONCLUSIONS

DM may directly hinders spinal cord conduction recovery in DCM patients after surgery. Corticospinal tract impairments are similar between DCM and DCM-DM patients, but significantly worsened in chronic or insulin-dependent DM patients. The dorsal column is more sensitively affected in all DCM-DM patients. Deeper investigation into the mechanisms and neural regeneration strategies is needed.

Early Experience With an Endocrinology Preoperative Fast-Track Program for Optimizing Spine Surgery Candidates With Poorly Controlled Diabetes Mellitus

INTRODUCTION

Previous studies demonstrated an increase in adverse outcomes for patients undergoing elective surgeries with poorly controlled diabetes mellitus. At a large, tertiary-care spine center with a notable population of patients with poorly controlled diabetes, an Endocrinology Fast-Track (EFT) program was developed to improve patient optimization before elective spine surgery. The purpose of this study was to report our early experience.

METHODS

Seventy-five patients who were scheduled for elective spine surgery were noted to have Hgb A1c > 7 on preoperative evaluation. Thirty-two patients accepted referral to the EFT program and 43 declined (non-EFT). Mean preoperative Hgb A1c was similar between groups (EFT: 8.79 versus non-EFT: 9.26, P = 0.221). The Fast-Track program included counseling, education, and medical management.

RESULTS

Patients in the two groups were similar in number of females (EFT: 17 versus non-EFT: 17, P = 0.348), age (EFT: 57.7 versus non-EFT: 60.6, P = 0.280), and body mass index (EFT: 34.6 versus non-EFT: 33.0, P = 0.341). A smaller number of smokers were there in the EFT group (1) compared with the non-EFT group (15, P = 0.003). The proportion of patients on insulin (EFT: 19 versus non-EFT: 23, P = 0.814) and oral hypoglycemics (EFT: 29 versus non-EFT: 39, P = 0.983) was similar between the two groups. Surgical clearance for patients with a documented preoperative Hgb A1c of < 7 or equivalent fructosamine level was significantly better in the Fast-Track group compared with the non-Fast-Track group (91% versus 42%, P = 0.000). Although most patients who declined the Fast-Track program did not obtain clearance for surgery, mean Hgb A1c was improved at the latest follow-up in both groups for those who obtained surgical clearance (7.10 versus 6.78, P = 0.470).

DISCUSSION

A novel EFT program was successful in obtaining acceptable blood glucose control in patients recommended for spine surgery who had poorly controlled diabetes mellitus on preoperative evaluation. The improved blood glucose control was maintained at the latest follow-up.

The Natural History of Degenerative Cervical Myelopathy

Degenerative cervical myelopathy (DCM) is the most frequent cause of spinal cord dysfunction and injury in the adult population and leads to significant loss of quality of life and economic impact from its associated medical care expenditures and loss of work. Surgical intervention is recommended for patients manifesting progressing neurological signs and symptoms of myelopathy, but the optimal management in individuals who have mild and clinically stable disease manifestations is controversial. Understanding the natural history of DCM is, thus, important in assessing patients and identifying those most appropriately indicated for surgical management. Despite the attempts to rigorously perform studies of the natural history of these patients, most published investigations suffer from methodological weaknesses or are underpowered to provide definitive answers. Investigations of particular patient subsets, however, provide some clinical guidance as to which patients stand most to benefit from surgery, and these may include those with lower baseline mJOA scores, evidence of segmental hypermobility, cord signal changes on MRI, abnormal somatosensory or motor-evoked potentials, or the presence of certain inflammatory markers. Clinicians should assess patients with mild myelopathy and those harboring asymptomatic cervical spinal cord compression individually when making treatment decisions and an understanding of the various factors that may influence natural history may aid in identifying those best indicated for surgery. Further investigations will likely identify how variables that affect natural history can be used in devising more precise treatment algorithms.

Effect of diabetes on patient-reported outcome measures at one year after laminoplasty for cervical spondylotic myelopathy

Although patients with diabetes reportedly have more peripheral neuropathy, the impacts of diabetes on postoperative recovery in pain and patient-reported outcome measures (PROMs) after laminoplasty for cervical spondylotic myelopathy (CSM) is not well characterized. The authors aimed to elucidate the effects of diabetes on neck/arm/hand/leg/foot pain and PROMs after laminoplasty CSM. The authors retrospectively reviewed 339 patients (82 with diabetes and 257 without) who underwent laminoplasty between C3 and C7 in 11 hospitals during April 2017 –October 2019. Preoperative Numerical Rating Scale (NRS) scores in all five areas, the Short Form-12 Mental Component Summary, Euro quality of life 5-dimension, Neck Disability Index, and the Core Outcome Measures Index-Neck) were comparable between the groups. The between-group differences were also not significant in NRS scores and PROMs one year after surgery. The change score of NRS hand pain was larger in the diabetic group than the nondiabetic group. The diabetic group showed worse preoperative score but greater improvement in the Short Form-12 Physical Component Summary than the nondiabetic group, following comparable score one year after surgery. These data indicated that the preoperative presence of diabetes, at least, did not adversely affect pain or PROMs one year after laminoplasty for CSM.

Intraoperative ultrasonography in laminectomy for degenerative cervical spondylotic myelopathy: a clinical and radiological evaluation

Background

The incidence of cervical myelopathy due to spinal stenosis is constantly growing in an aging population. Especially in multisegmental disease, dorsal laminectomy is the intervention of choice. Intraoperative imaging with ultrasound might provide additional information about extent and sufficiency of spinal cord decompression.

Methods

In this prospective study, the width of the subarachnoid space was systematically measured by intraoperative ultrasound at predefined sites at the cranial and caudal edge of decompression in axial and sagittal reconstruction. These data were compared with corresponding sites on postoperative T2-weighted MRI imaging. In addition, the functional outcome was assessed by modified Japanese Orthopaedic Association (mJOA) score. A historical patient cohort treated without ultrasound-guided laminectomy served as control group.

Results

Altogether, 29 patients were included. According to mJOA score at last follow-up, 7/29 patients reported stable symptoms and 21/29 patients showed a substantial benefit with no or minor residual neurological deficits. One patient suffered from a new C5 palsy. Intraoperative ultrasound-guided posterior decompression provided excellent overview in all cases. Measurement of the width of the subarachnoid space acquired by intraoperative ultrasound and postoperative MRI images showed a very high correlation, especially at the cranial level (p < 0.001, r = 0.880). Bland–Altman analysis showed that most patients were within the 1.96 × SD limits of agreement throughout all measurements. No ultrasound procedure-related complications were observed. Compared to a historical cohort of 27 patients, no significant differences were found regarding functional outcome (p = 0.711).

Conclusion

Intraoperative sonography visualises the surgically achieved restoration of the subarachnoid space in good correlation with postoperative MRI and might serve as a fast, precise and reliable tool for intraoperative imaging in cervical laminectomy. However, we could not demonstrate a clinical benefit with regard to functional outcome.

Diabetes Mellitus-A Risk Factor for the Development of Lumbar Disc Degeneration: A Retrospective Study of an Indian Population

STUDY DESIGN

A retrospective study.

OBJECTIVES

To determine the association between type-2 diabetes mellitus (T2DM) and the severity of lumbar disc degeneration disease (LDDD).

METHODS

We included 199 patients with low back pain (LBP) who visited our hospital from 2016 to 2018. All patients were divided into 3 groups as per inclusion criteria. Group A, patients without DM (n = 75); group B, patients with controlled DM (n = 72); and group C, patients with uncontrolled DM (n = 52). The patients were further subdivided into group B1, DM duration ≤10 years (n = 38); group B2, DM duration >10 years (n = 34); group C1 DM duration ≤10 years (n = 28); and group C2, DM duration >10 years (n = 24). Sex, age, body mass index, occupation, smoking history, alcohol use, and duration of T2DM were recorded. The severity of LDDD was evaluated using the 5-level Pfirrmann grading system. Operated patients' disc materials were sent for histological examination.

RESULTS

Demographic data showed no difference among groups (P > 0.5), except age. Patients with DM showed more severe disc degeneration compared with patients without DM. The average Pfirrmann scores between groups A and B1 had no difference; groups B2, C1, and C2 showed higher average Pfirrmann scores than group A (P < 0.05). Groups B2 and C2 showed higher average Pfirrmann scores than groups B1 and C1 (P < 0.05). Groups C1 and C2 showed higher average Pfirrmann scores than groups B1 and B2 (P < 0.05). The severity of LDDD was significantly related to DM duration in both groups B and C (P < 0.05). DM groups showed increased disc apoptosis and matrix aggrecan fragmentation, disc glycosaminoglycan content and histological analysis were significantly different; the results are similar to Pfirrmann score results.

CONCLUSIONS

DM duration >10 years and uncontrolled DM were risk factors for LDDD.

The influence of carotid atherosclerosis on surgical outcomes of patients with cervical spondylotic myelopathy: A retrospective study

The appearance of atherosclerosis in the carotid artery may be suggest the possibility of atherosclerosis in the spinal cord artery, which can cause spinal cord ischemia and further lead to neural element damage.According to the inclusion and exclude standard, there are 137 patients with cervical spondylotic myelopathy (CSM) incorporating retrospective analysis. These patients were consecutively admitted into The Second Hospital- Cheeloo College of Medicine-Shandong University from January 2016 to December 2018 and have accepted surgical treatment. All patients were examined by color Doppler ultrasound to detect carotid atherosclerosis before surgery. All patients were divided into 2 groups according to the presence or absence of carotid atherosclerosis: carotid atherosclerosis group (n = 88) and noncarotid atherosclerosis group (n = 49). All patients were followed up for at least 12 months after surgery. Demographic and surgery-related data were collected and analyzed to identify potential factors that affect the surgical outcomes in CSM.The average age of carotid atherosclerosis group (51 males and 37 females), and noncarotid atherosclerosis group (24 males and 25 females) were 62.02 ± 10.34 years (range, 38-85 years) and 49.61 ± 10.28 years (range, 26-67 years), respectively.In carotid atherosclerosis group: pre and postoperative modify Japanese Orthopedic Association Scores (mJOA score) were 11.58 ± 1.82 and 14.36 ± 1.64; the recovery rate of mJOA score was 45.57% ± 13.28%. In noncarotid atherosclerosis group: pre and postoperative mJOA score were 12.00 ± 2.11 and 15.04 ± 1.70; the recovery rate of mJOA score was 53.90% ± 13.22%. Univariate logistic regression analysis demonstrated that gender (P = .004), age ≥65 years (P = .001), duration of symptoms ≥12 months (P = .040), smoking history (P < .001), preoperative mJOA score ≤11 (P = .007) and carotid atherosclerosis (P = .004) were related to poor surgical outcomes. Multivariate logistic regression analysis showed significant correlations between poor surgical outcomes and age ≥65 years (P = .047), smoking history (P = .010), preoperative mJOA score ≤11 (P = .008) or carotid atherosclerosis (P = .047).Carotid atherosclerosis may be a risk factor for poor surgical outcomes in CSM.

Optimizing the Application of Surgery for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 10]

STUDY DESIGN

Literature Review (Narrative).

OBJECTIVE

To introduce the number 10 research priority for Degenerative Cervical Myelopathy: Individualizing Surgery.

METHODS

This article summarizes the current recommendations and indications for surgery, including how known prognostic factors such as injury time, age, disease severity, and associated comorbidities impact surgical outcome. It also considers key areas of uncertainty that should be the focus of future research.

RESULTS

While a small proportion of conservatively managed patients may remain stable, the majority will deteriorate over time. To date, surgical decompression is the mainstay of treatment, able to halt disease progression and improve neurologic function and quality of life for most patients. Whilst this recognition has led to recommendations on when to offer surgery, there remain many uncertainties including the type of surgery, or timing in milder and/or asymptomatic cases. Their clarification has the potential to transform outcomes, by ensuring surgery offers each individual its maximum benefit.

CONCLUSION

Developing the evidence to better guide surgical decision-making at the individual patient level is a research priority for Degenerative Cervical Myelopathy.

Factors Negatively Influencing Postoperative Improvement After Laminoplasty in Degenerative Cervical Myelopathy

STUDY DESIGN

This was a retrospective study of prospectively collected data.

OBJECTIVE

In this study, we aimed to characterize a population of patients with degenerative cervical myelopathy (DCM) and a history of poor postoperative neurological recovery and to identify risk factors associated with poor neurological recovery after laminoplasty.

SUMMARY OF BACKGROUND DATA

Kyphotic cervical alignment has been considered a relative contraindication to laminoplasty in recent years; hence, laminoplasty has been decreasingly performed for the treatment of DCM in patients with cervical kyphosis. However, the effect of global spinal alignment on postoperative outcomes has not been extensively investigated.

MATERIALS AND METHODS

We prospectively enrolled patients who were scheduled for laminoplasty for DCM. Outcome (at enrollment and 1 y after surgery) and risk factor analyses were performed by comparing the good recovery and poor recovery groups. The Spearman correlation coefficient was used to evaluate the relationships between the recovery rate and the preoperative radiographic factors.

RESULTS

In total, 101 patients completed the 1-year follow-up. Regarding clinical outcomes, the Japanese Orthopedic Association score for the assessment of cervical myelopathy, European Quality of Life-5 Dimensions, and Neck Disability Index scores improved postoperatively. The recovery rate was significantly correlated with the preoperative sagittal vertical axis (SVA). The patients in the poor recovery group were older than those in the good recovery group. Univariate analyses showed that the SVA and T1 pelvic angle were significantly higher in the poor recovery group. Lastly, stepwise logistic regression analysis showed that a higher SVA was an independent predictor of poor recovery after laminoplasty.

CONCLUSIONS

The SVA and T1 pelvic angle were significantly higher in the poor recovery group. A high preoperative SVA is an independent predictor for poor recovery after laminoplasty. Therefore, indications for laminoplasty in elderly DCM patients with a high preoperative SVA should be carefully considered.

LEVEL OF EVIDENCE

Level III.

Diabetes Mellitus and the Development of Lumbar Canal Stenosis: Is There Any Relevance?

Study Design

Retrospective study.

Purpose

To assess the relationship between the severity of lumbar canal stenosis (LCS) and type-II diabetes mellitus (DM).

Overview of Literature

DM is a multiorgan disorder that has an effect on all types of connective tissues. LCS is a narrowing of the spinal canal with nerve root impingement that causes neurological claudication and radiculopathy. Identification of the risk factors of LCS is key in the prevention of its onset or progression.

Methods

LCS patients were divided into three groups as per DM status: group A without DM (n=150); group B patients with well-controlled DM; and group C patients with uncontrolled DM. Groups B and C were subdivided into group B1: patients with DM with a duration of ≤10 years (n=76), group B2: DM with duration of >10 years (n=68), group-C1 DM duration ≤10 years (n=56), and group C2 DM duration >10 years (n=48). The severity of LCS was evaluated using the Swiss Spinal Stenosis Scale (SSSS) and Modified Oswestry Disability score (MODS). Operated patients ligamentum flavum sent for histological staining and quantitative immunofluorescence analysis.

Results

The demographic data of groups did not show any difference except in age. There was no difference between the mean SSSS and MODS of groups A and B1. Groups B2, C1, and C2 had higher average SSSS and MODS than group A (p<0.05). Groups B2 and C2 had higher SSSS and MODS than groups B1 and C1. Groups C1 and C2 had higher scores than groups B1 and B2 (p<0.05). The severity of LCS was significantly related to the duration of DM in groups B and C (p<0.05). Uncontrolled and longer duration of DM had significant elastin fibers loss and also higher rate of disk apoptosis, high matrix aggrecan fragmentation, and high disk glycosaminoglycan content.

Conclusions

Longer duration and uncontrolled diabetes were risk factors for LCS and directly correlate with the severity of LCS.

Diabetes Does Not Adversely Affect Neurological Recovery and Reduction of Neck Pain After Posterior Decompression Surgery for Cervical Spondylotic Myelopathy: Results From a Retrospective Multicenter Study of 675 Patients

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

The aim of this study was to identify the impact of diabetes on surgical outcomes of posterior decompression for cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

Although some previous studies have reported surgical outcomes of posterior decompression for CSM in diabetic patients, their results were inconsistent.

METHODS

We included 675 patients with CSM who underwent posterior decompression. Patients were divided into diabetic (n = 140) and nondiabetic (n = 535) groups according to the diabetic criteria for glucose intolerance. Surgical outcomes as assessed by the Japanese Orthopedic Association (JOA) scores and visual analog scale (VAS) for neck pain were compared between groups. Subsequently, the functional outcomes of diabetic patients were compared between the mild (n = 131) and moderately severe (n = 9) groups. All patients were followed up for at least 1 year after surgery.

RESULTS

Compared with the nondiabetic group, the diabetic group showed lower pre- and postoperative JOA scores (P = 0.025 and P = 0.001, respectively) and a lower JOA score recovery rate (RR) (P = 0.009). However, the preoperative-to-postoperative changes in JOA scores in the diabetic and nondiabetic groups were not significantly different (P = 0.988). Pre- and postoperative VAS for neck pain and postoperative reduction of neck pain were comparable between groups (P = 0.976, P = 0.913 and P = 0.688, respectively). Although statistical analysis was not performed due to the small underpowered sample size, functional outcomes assessed by the JOA score RR (43.3 ± 37.1% vs. 45.3 ± 33.9%) and preoperative-to-postoperative changes in JOA scores (3.0 ± 2.2 vs. 2.7 ± 2.5) were similar between the mild and moderately severe diabetes groups.

CONCLUSION

CSM patients with diabetes experienced improvements in neurological function and neck pain as a result of posterior decompression to the same extent seen in patients without diabetes.Level of Evidence: 3.

Risk Factors for Poor Outcome of Cervical Laminoplasty: Multivariate Analysis in 505 Patients with Cervical Spondylotic Myelopathy

The risk factors for poor outcome after cervical laminoplasty in patients with cervical spondylotic myelopathy (CSM) were demonstrated. These findings suggest that advanced age, long-term CSM symptoms, and lower score of preoperative 10-second step test are risk factors for poor cervical laminoplasty outcomes in patients with CSM.

Study Design..

A prospective study.

Objective..

The aim of this study was to characterize the risk factors for poor outcome following cervical laminoplasty in patients with cervical spondylotic myelopathy (CSM).

Summary of Background Data..

Previous research has identified a variety of potential predictive factors that might affect outcomes after cervical laminoplasty. However, no study till date has assessed the effects of such risk factors, including internal medicine comorbidity and quantitative performance tests, on the outcome of laminoplasty in a large series of patients with CSM.

Methods..

A total of 505 consecutive patients with CSM (311 males; 194 females; mean age, 66.6 years; age range, 41–91 years) who underwent double-door laminoplasty were prospectively included. The average postoperative follow-up period was 26.5 months (range, 12–66 months). We evaluated the recovery rate (RR) on the basis of the Japanese Orthopaedic Association score. Logistic regression analysis was performed to identify the risk factors for poor outcome, which was defined as a postoperative RR of <50%. Relationship between outcome and various clinical and imaging predictors was examined.

Results..

Two hundred ninety-five patients had good outcomes with RR >50%, whereas 210 patients had poor outcomes with RR <50%. Compared with the good-outcome group, the poor-outcome group had a significantly higher prevalence of diabetes and hypertension and use of anticoagulant/antiplatelet agent and smoking history (P < 0.05). Multivariate logistic regression analysis showed independent risks associated with increased age (odds ratio [ORs]  = 1.029, 95% confidence interval [CI] = 1.004–1054, P = 0.023). Logistic regression analysis determined that symptom duration of CSM (OR = 1.017, 95% CI = 1.008–1.026, P < 0.001) and preoperative 10-second step test (OR = 0.922, 95% CI = 0.865–0.983, P = 0.013) were significant risk factors for poor outcome.

Conclusion..

These findings suggest that advanced age, long-term CSM symptoms, and lower score of preoperative 10-second step test are risk factors for poor outcome in patients with CSM.

Level of Evidence: 2

Prediction of outcome following laminoplasty of cervical spondylotic myelopathy: Focus on the minimum clinically important difference

The minimum clinically important difference (MCID) of the Japanese Orthopaedic Association (JOA) score has been reported to be around 2.5 points in cervical myelopathy. This study sought to define significant predictive factors on achieving the MCID following laminoplasty in a large series of patients with cervical spondylotic myelopathy (CSM). A total of 485 consecutive patients with CSM (295 males and 190 females; mean age: 67.0 years; age range: 42-91 years) who underwent laminoplasty were prospectively enrolled. The average postoperative follow-up period was 26.6 months (range: 12-66 months). We calculated the achieved JOA score. The relationships between outcomes and various clinical and imaging predictors including comorbidity and quantitative performance tests were examined. Logistic regression analysis was conducted to identify the predictors correlated with a JOA score of 2.5 points or more. Clinically meaningful gains were exhibited in 299 patients (61.6%) with a JOA score of ≥2.5 points, whereas 186 patients (38.4%) achieved a JOA score of <2.5 points. Univariate logistic regression analysis showed the predictive factors with a shorter duration of CSM symptoms, lower preoperative JOA scores, absence of hypertension, no use of anticoagulant/antiplatelet agents, and nonsmoking status. Multivariate logistic regression analysis determined that the duration of CSM symptoms (odds ratio: 0.771, 95% confidence interval: 0.705-0.844; p < 0.01) was the only significant predictive factor for achieving JOA scores of ≥2.5 points. An important predictor of MCID achievement following laminoplasty was shorter duration of CSM symptoms.

Effect of Titanium Miniplate Fixation on Hinge Fracture and Hinge Fracture Displacement Following Cervical Open-Door Laminoplasty

BACKGROUND

Cervical spondylotic myelopathy is a neuromotor disorder responsible for functional limitations and decreased daily activities. Expansive open-door laminoplasty is the widely accepted procedure for the treatment of multilevel cervical spondylotic myelopathy. Among the various fixation procedures to secure the open lamina, miniplate fixation provides better clinical and radiological outcomes. However, the immediate effects on hinge fracture and hinge fracture displacement following miniplate fixation have not been proven until now. The purpose of our study was to elucidate the impact of cervical open-door angle on the status of spinal cord expansion and hinge fracture, hinge fracture displacement, and the role of implants used during surgery.

METHODS

For this retrospective study, 122 patients who had undergone surgery from September 2016 to November 2017 with preoperative and postoperative radiographs were enrolled. Clinical and radiological outcomes were assessed before and after surgery.

RESULTS

There were no significant differences in demographics, surgery time, blood loss, medical comorbidities, or perioperative and postoperative complications between 2 groups. The recovery rate and Nurick score before and at the follow-up show no statistical significance between the 2 groups, P value > .05 (P = .672) and P > .05 (P = .553), respectively. The statistical analysis shows that the mean hinge fracture in the miniplate group with a cervical open angle >30° was 2.42 ± 1.68 and with a <30° open angle, 0.05 ± 0.23; whereas, in the anchor group the mean hinge fracture in >30° cervical open angle was 2.227 ± 2.50 and in <30° was 0.409 ± 0.503. The results revealed statistical significance between 2 implant groups, P = .024 in the aspect of hinge fracture displacement and implant used.

CONCLUSION

Laminoplasty by titanium miniplate fixation holds the laminae securely, prevents hinge fracture displacement, and promotes spinal cord expansion better than suture anchor fixation.

Hyperglycemia and its influence on development of lumbar degenerative disc disease

Study Design

Objectives

Methods

Results

Conclusions

Degenerative Cervical Myelopathy: Review of Surgical Outcome Predictors and Need for Multimodal Approach

Degenerative cervical myelopathy is the most common cause of spinal cord injury in the elderly population in the developed world, and it significantly affects the quality of life of patients and their caregivers. Surgery remains the only treatment option able to halt disease progression and provide neurological recovery for most patients. Although it has remained challenging to predict exactly who will experience improvement after surgery, increasingly it has been shown that clinical, imaging, and electrophysiological factors can predict, with relatively good capacity, those more likely to benefit. Clinically, the baseline neurological impairment appears to be strongly related to the outcome, and the magnetic resonance imaging findings of T1-weighted hypointensity and the length of T2-weighted hyperintensity appear to be the most prognostic. In this context, electrophysiology findings (both motor and sensory evoked potentials) have shown some predictive capacity. However, large studies are lacking. Although multivariate models have been conducted using clinical and magnetic resonance imaging data, no multimodal prediction models are available that encompass the predictive capacity of clinical, imaging, and electrophysiological data. In the present review, we examined the rationale for clinical, imaging, and electrophysiological usage in clinical practice and discussed a model of multimodal assessment for the management of degenerative cervical myelopathy.

Degenerative cervical myelopathy - update and future directions

Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord dysfunction in adults worldwide. DCM encompasses various acquired (age-related) and congenital pathologies related to degeneration of the cervical spinal column, including hypertrophy and/or calcification of the ligaments, intervertebral discs and osseous tissues. These pathologies narrow the spinal canal, leading to chronic spinal cord compression and disability. Owing to the ageing population, rates of DCM are increasing. Expeditious diagnosis and treatment of DCM are needed to avoid permanent disability. Over the past 10 years, advances in basic science and in translational and clinical research have improved our understanding of the pathophysiology of DCM and helped delineate evidence-based practices for diagnosis and treatment. Surgical decompression is recommended for moderate and severe DCM; the best strategy for mild myelopathy remains unclear. Next-generation quantitative microstructural MRI and neurophysiological recordings promise to enable quantification of spinal cord tissue damage and help predict clinical outcomes. Here, we provide a comprehensive, evidence-based review of DCM, including its definition, epidemiology, pathophysiology, clinical presentation, diagnosis and differential diagnosis, and non-operative and operative management. With this Review, we aim to equip physicians across broad disciplines with the knowledge necessary to make a timely diagnosis of DCM, recognize the clinical features that influence management and identify when urgent surgical intervention is warranted.

Trauma in the Diabetic Limb

Poorly controlled diabetes with comorbid manifestations negatively affects outcomes in lower extremity trauma, increasing the risk of short-term and long-term complications. Management strategies of patients with diabetes that experience lower extremity trauma should also include perioperative management of hyperglycemia to reduce adverse and serious adverse events.

Minimum Clinically Important Difference and Patient Acceptable Symptom State of Japanese Orthopaedic Association Score in Degenerative Cervical Myelopathy Patients

STUDY DESIGN

A retrospective analysis.

OBJECTIVE

The aim of this study was to elucidate the psychometric properties of the original Japanese Orthopaedic Association (JOA) score, including the minimum detectable change (MDC), minimum clinically important difference (MCID), and patient-accepted symptom state (PASS).

SUMMARY OF BACKGROUND DATA

Despite the worldwide popularity of modified JOA score (mJOA), the original JOA score is still commonly used in East Asian countries, including Japan. However, unlike mJOA score, the psychometric properties of JOA score remain poorly understood.

METHODS

We retrospectively reviewed a consecutive series of laminoplasty for degenerative cervical myelopathy patients in a single academic institution. Pre- and postoperative JOA scores were collected, and the recovery rate was calculated. Anchor-based methods were used to determine the cut-off values by a receiver operating characteristic (ROC) curve analysis. The patients were also asked to answer an anchor question analyzing their postoperative health transition used for the MDC and another question assessing the patient satisfaction used for the MCID and PASS.

RESULTS

A total of 101 patients were included in the analysis. The mean preoperative JOA score was 10.3 [standard deviation (SD): 2.4), and the mean postoperative JOA score was 13.4 (SD: 2.5). The mean recovery rate was 44%. A total of 68% of the patients admitted that their health condition was at least "somewhat better" than their preoperative condition, and 66% were at least "somewhat satisfied" with the treatment results. On the basis of ROC curve analyses, the MDC and MCID for JOA score in degenerative cervical myelopathy patients were calculated to be 2.5. The PASS was estimated to be 14.5, and the MCID for JOA recovery rate was 52.8%.

CONCLUSION

The MDC, MCID, and PASS for JOA score for degenerative cervical myelopathy patients were reported by anchor-based ROC curve analyses.

LEVEL OF EVIDENCE

4.

Medium-term clinical outcomes of laminoplasty with adjunct short anterior fusion in multilevel cervical myelopathy

Objectives:

Expansive open-door laminoplasty (EOLP) is effective for multilevel cervical spondylotic myelopathy (MCSM). When MCSM is combined with one- or two-level segmental kyphosis, instability, or major anterior foci, EOLP with short-segment anterior cervical fusion (ACF) results in good short-term neurological recovery and can preserve postoperative range of motion (ROM). The objective of this study was to evaluate the medium-term clinical outcomes of this procedure and to analyze the risk factors affecting the neurological function at the last follow-up.

Materials and Methods:

A total of 87 patients were enrolled in this retrospective study conducted from January 2007 to May 2011. These patients exhibited MCSM with combined short segmental kyphosis, instability, or major anterior pathology, and received EOLP and short-segment anterior fusion. The follow-up period lasted at least 60 months. The radiographic outcomes were collected from plain radiographs with dynamic views checked preoperatively and at the last follow-up. Neurological status and visual analog scale scores for neck pain were evaluated. Logistic regression analysis was then applied to determine the correlation between radiographic parameters and rates of neurological recovery.

Results:

The mean Japanese Orthopedics Association recovery rate at the last follow-up was 77.8%. The improvement in functional scores and reduction in neck pain were statistically significant. The most influential risk factor affecting neurologic recovery was preoperative functional status.

Conclusions:

EOLP followed by short-segment ACF is a favorable treatment for patients with MCSM with concomitant short-segment kyphosis, instability, or major anterior pathology.

Cervical spondylotic myelopathy patients with prior cerebral infarction: Clinical characteristics, surgical outcomes and prognostic value of "prior cerebral infarction"

OBJECTIVE

To investigate the clinical characteristics and surgical outcomes of patients with cervical spondylotic myelopathy (CSM) and prior cerebral infarction (CI); to identify whether "prior CI" correlates with poor surgical outcomes.

PATIENTS AND METHODS

Twenty-two patients with CSM and prior CI were retrospectively reviewed and included as the CI group while 100 CSM patients without CI were included as the control group (matched for gender, age, symptom duration and surgical approach). Extensive demographic and surgery-related data for patients in both groups were collected and compared. Multivariate logistic regression analysis was performed to assess all potential factors affecting surgical outcomes.

RESULTS

Compared to the control group, the CI group had the following: significantly higher percentages of hypertension, "progressive myelopathy", "rapid progressive myelopathy" and "intramedullary T2-weighted hyperintensity on MRI"; lower mean "preoperative mJOA score" and "postoperative mJOA score"; higher percentages of "preoperative mJOA score ≤11″ and "recovery rate of mJOA score <50%". In the CI group, 14 patients had CI within 6 months before CSM, and their percentage of "rapid progressive myelopathy" was higher than that of patients who had CI over 6 months before CSM. Logistic regression analysis showed that smoking, "symptom duration ≥12 months", "T2-weighted hyperintensity" and "prior CI" correlated with poor surgical outcome.

CONCLUSION

Rapid progressive myelopathy with advanced neurological impairment and "intramedullary T2-weighted hyperintensity" are common in patients with CSM and prior CI. Surgical outcomes in these patients are poorer than those of ordinary CSM patients. "Prior CI" is a risk factor for predicting poor surgical outcomes.

Poorer Fusion Outcomes in Diabetic Cervical Spondylotic Myelopathy Patients Undergoing Single-level Anterior Cervical Discectomy and Fusion Does Not Compromise Functional Outcomes and Quality of Life

STUDY DESIGN

Retrospective matched pair cohort study using prospectively collected registry data.

OBJECTIVES

The aim of this study was to determine whether patients with DM have poorer patient-reported outcomes and poorer fusion rates after undergoing a single-level anterior cervical discectomy and fusion (ACDF) for cervical myelopathy.

SUMMARY OF BACKGROUND DATA

ACDF remains the most common procedure in the treatment of cervical spondylotic myelopathy (CSM); however, there is a paucity of literature with regards to patient-reported outcome measures (PROMs), health-related quality-of-life (HRQOL) scores, and fusion rates post-ACDF in diabetic patients with CSM.

METHODS

From 2002 to 2012, 29 diabetic patients were matched with 29 nondiabetic controls. Patient demographics, perioperative data, and validated spine-specific scores including the Numerical Pain Rating Scale on Neck Pain and Upper Limb Pain, American Academy of Orthopaedic Surgeons (AAOS) neck pain and disability scores, AAOS Neurogenic Symptoms Score, Neck Disability Index, Japanese Orthopaedic Association Cervical Myelopathy Score, and Short Form 36 Physical/Mental Component Summaries were recorded. Fusion rates based on Bridwell grading were assessed at 2 years.

RESULTS

After matching, there were no significant preoperative differences in patient demographics, clinical outcomes, PROMs or HRQoL measures between the DM and control group (P > 0.05). There was no difference in either length of hospital stay (P = 0.92) or length of surgery (P = 0.92) between the two groups. At 2 years postoperatively, there were no significant differences between validated spine-specific scores, PROMs, HRQoL scores, satisfaction rates, or fulfilment of expectations between the two groups. Significant poorer Bridwell fusion grades were noted in the DM group at 2 years postoperatively (P < 0.05). Subgroup analysis within the DM group demonstrated that glycated hemoglobin levels had no impact on functional outcomes, fulfilment of expectations, or patient satisfaction at 2 years (P > 0.05).

CONCLUSION

Despite poorer fusion outcomes following single-level ACDF for symptomatic CSM, there was no significant difference in validated spine outcome scores, PROMs, HRQoL measures, or satisfaction levels when compared to nondiabetic controls at short-term follow-up.

LEVEL OF EVIDENCE

3.

The potential effect of type 2 diabetes mellitus on lumbar disc degeneration: a retrospective single-center study

Background

Diabetes mellitus (DM) and low back pain which is mainly caused by degeneration of the intervertebral discs (IVDs) both are major public health problem worldwide. The present study was designed to investigate the association between type 2 diabetes mellitus (T2D) and severity of lumbar disc degeneration (LDD).

Methods

We retrospectively reviewed patients with low back pain visiting our spine clinic in 2014. Low back pain patients all have the lumbar MRI imaging and no previous treatment. One hundred fifty patients without T2D (group A) and 622 patients with T2D meeting the criteria were included. Sex, age, body mass index (BMI), high blood pressure (HBP), history of smoking, alcohol use, and duration of T2D were recorded. Patients with T2D were assigned to a well-controlled group (group B, n = 380) and a bad-controlled group (group C, n = 242). In group B, T2D duration of 148 patients was ≤ 10 years (group B1) and 232 patients > 10 years (group B2). In group C, T2D duration of 100 patients was ≤ 10 years (group C1) and 142 patients > 10 years (group C2). The severity of LDD was evaluated using the five-level Pfirrmann grading system. Data were analyzed using SPSS 19.0.

Results

Demographic data except age showed no difference among groups (P > 0.5). Compared to patients without T2D, patients with T2D showed more severe disc degeneration after removal of age effects (P < 0.05). From L1/2 to L5/S1, the average Pfirrmann scores between groups A and B1 showed no difference(P > 0.05); groups B2, C1, and C2 showed higher average Pfirrmann scores than group A (P < 0.05). Groups B2 and C2 showed higher average Pfirrmann scores than groups B1 and C1 (P < 0.05). Groups C1 and C2 showed higher average Pfirrmann scores than groups B1 and B2 (P < 0.05). From L1/2 to L5/S1, the severity of LDD was highly positively related to T2D duration both in groups B and C (P < 0.05).

Conclusions

T2D duration > 10 years and a bad control of T2D were risk factors for LDD. The longer T2D duration was, the more severe disc degeneration would be.

Managing the Complex Patient with Degenerative Cervical Myelopathy: How to Handle the Aging Spine, the Obese Patient, and Individuals with Medical Comorbidities

Degenerative cervical myelopathy (DCM) is the most common cause of nontraumatic spinal cord injury worldwide. Even relatively mild impairment in functional scores can significantly impact daily activities. Surgery is an effective treatment for DCM, but outcomes are dependent on more than technique and preoperative neurologic deficits.

Impact of wedge-shaped resection of the posterior bony arch on postoperative outcomes after open door laminoplasty in the cervical spine: a 2-year follow-up study

BACKGROUND CONTEXT

Open door laminoplasty (ODLP) can also lead to significant postoperative motion restriction that further increases over time, for which one of the possible factors is the bony impingement between neighboring posterior bony arches. Previously, we reported this phenomenon and modified technique of ODLP, wedge-shaped resection of the posterior bony arch that produced greater range of motion (ROM) of the cervical spine and less posterior neck pain compared with conventional ODLP (cODLP) in 1-year follow-up time, but no longer follow-up outcomes of the surgical technique has been reported.

PURPOSE

The study aimed to thoroughly evaluate the impact of posterior bony impingement following ODLP on postoperative cervical motion and related outcomes, and to compare postoperative outcomes of conventional ODLP (cODLP with those of modified ODLP (mODLP) in 2-year follow-up times.

STUDY DESIGN

This is a retrospective comparative study.

PATIENT SAMPLE

A total of 145 patients who underwent cODLP or mODLP and were followed up for at least 2 years were classified into two groups: Group A (cODLP, 79 patients) and Group B (mODLP, 66 patients).

OUTCOME MEASURES

The primary outcome measure was ROM of the cervical spine. Secondary outcome measures included (1) patient satisfaction, (2) radiological outcomes, including the rate of bony impingement and spontaneous fusion, and bone regrowth of the resection site, (3) clinical outcomes based on pain intensity and scores on the 12-item short-form health survey (SF-12) and neck disability index (NDI), (4) surgical outcomes, and (5) surgery-related complications.

METHODS

We compared baseline data in both groups. To evaluate the impact of our surgical modification on postoperative outcome after ODLP, we compared the outcome measures in 2-year follow-up times. No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

RESULTS

The ROM of the cervical spine was significantly greater in Group B 2 years after surgery than in Group A (p=.001). Patient satisfaction (p=.02) at 2 years after surgery and pain intensity of the posterior neck at 1 (p=.01) and 2 years (p<.01) after surgery were better in Group B than in Group A. Radiological evidence of posterior bony impingement and spontaneous fusion between ODLPsegments were definitely fewer less in Group B than in Group A (p<.001 and<0.001, respectively). The mean value of bone regrowth was 1.2 mm (range, 0-3 mm). The NDI and SF-12 scores did not differ significantly between groups. Surgical outcomes and postoperative complications were similar between groups.

CONCLUSIONS

These results indicate that posterior bony impingement can be a factor in ROM restriction after cODLP surgery and that wedge-shaped resection during ODLP can be a reliable option for preserving cervical ROM and improving postoperative clinical and radiological outcomes.

Which Technique Is Better Option for C3 Segment in Multilevel Open-Door Laminoplasty of the Cervical Spine?: Laminectomy Versus Laminoplasty

STUDY DESIGN

A post-hoc comparative study.

OBJECTIVE

To evaluate postoperative clinical, radiological, and surgical outcomes after laminoplasty (LP) involving the C3 segment and to compare outcomes with those of patients who underwent LP with C3 laminectomy (LN).

SUMMARY OF BACKGROUND DATA

In many of the pathologies that require LP involving C3 segment, most spine surgeons perform LP at C3 and other cervical segments. Considering the peculiarities of the C2-C3 level, spine surgeons should take into account those in LP involving the C3 segment, but the particular aspects of the C2-C3 levels have not been fully evaluated.

METHODS

Of 93 patients, 66 patients (39 in group A, LP involving C3; 27 in group B, LP with C3 LN) were enrolled in the study. The primary outcome measure was pain intensity of the posterior neck measured with visual analog scale. Secondary endpoints included the following: (1) radiologic outcomes based on the cervical range of motion and rate of bony impingement and spontaneous fusion between C2 and C3, (2) clinical outcomes based on the 12-item short-form health survey and Japanese Orthopedic Association scale, and (3) surgical outcomes.

RESULTS

The primary end-point of the present study, posterior neck pain, exhibited a greater improvement in the group with C3 LN than in the group with C3 LP at 6 months and 1 year after surgery (P = 0.03 and 0.01, respectively). The cervical range of motion of C3 LN group was significantly greater than C3 LP group at postoperative 1 year (P = 0.02). Radiologic evidences of bony impingement and spontaneous fusion between C2 and C3 were significantly greater in C3 LP group than in C3 LN group. Clinical outcomes and surgical outcomes did not differ significantly between groups.

CONCLUSION

We recommend performing LN instead of LP for the C3 segment in cases requiring multilevel LP surgery involving C3.

LEVEL OF EVIDENCE

3.

Characteristics of Residual Symptoms After Laminoplasty in Diabetic Patients With Cervical Spondylotic Myelopathy: A Prospective Cohort Study

STUDY DESIGN

A prospective cohort study.

OBJECTIVE

The purpose of this study was to compare cervical laminoplasty outcomes between diabetic and nondiabetic patients with cervical spondylotic myelopathy (CSM), and to characterize residual symptoms of diabetic patients.

SUMMARY OF BACKGROUND DATA

Diabetes is one of the most frequent comorbidities in CSM patients. However, no report has elucidated residual symptoms following surgery in diabetic patients with CSM.

METHODS

.: A total of 505 consecutive patients with CSM (331 males, 189 females; mean age, 66.6 years; age range, 41-91 years; >1-year follow up after laminoplasty) were enrolled and divided into diabetic group (n = 105) and nondiabetic group (n = 400). The Japanese Orthopedic Association (JOA) scores and recovery rate (RR) of each function were compared between the groups. To quantitatively assess performance, the 10-s grip and release (G&R) test and the 10-s step test were evaluated.

RESULTS

There was no significant difference in the mean RRs of upper extremity motor function between diabetic and nondiabetic patients (59.2% vs. 60.5%, respectively; P = 0.789). The RR of lower extremity motor function was lower in the diabetic group than in the nondiabetic group (36.1% vs. 43.4%, respectively; P = 0.047); the RR of upper extremity sensory function also was lower (36.8% vs. 49.6%, respectively; P = 0.006). However, the mean RRs of sensory functions of lower extremities were 59.7% (diabetic) and 59.2% (nondiabetic) (P = 0.953). There was no significant difference in the mean RRs of trunk sensory function between the groups (69.3% vs. 74.1%, respectively; P = 0.303). The mean RRs of urinary bladder function were 42.1% (diabetic) and 53.7% (nondiabetic) (P = 0.035). The preoperative mean number of the 10-s step test was lower in the diabetic group than in the nondiabetic group, and the postoperative mean number also was significantly lower in the diabetic group.

CONCLUSION

Gait disturbance, hand numbness, and bladder dysfunction after surgery persisted more than other symptoms in the diabetic than in the nondiabetic patients.

LEVEL OF EVIDENCE

2.

Prospective Comparison of Age- and Sex-related Differences in Quantifiable 10-S Grip and Release and 10-S Step Test Results for Diagnosis of Cervical Spondylotic Myelopathy in 454 Patients With Cervical Spondylotic Myelopathy and 818 Asymptomatic Subjects

STUDY DESIGN

A prospective comparison.

OBJECTIVE

The purpose of this prospective study was to verify the clinical effectiveness of the 10-s grip and release (G&R) and 10-s step quantitative tests for assessing the severity of cervical spondylotic myelopathy (CSM) and to compare age- and sex-related differences in the results between large cohorts of CSM patients and asymptomatic subjects.

SUMMARY OF BACKGROUND DATA

To determine the severity of CSM, objective and reproducible means of measuring patient disability are essential. No studies have evaluated differences in quantitative test results between a large series of CSM patients and healthy subjects.

METHODS

Four hundred fifty-four CSM patients and 818 asymptomatic subjects were included. The Japanese subjects were in their 40s to 70s and were divided according to their age by decade. The 10-s G&R and 10-s step tests were used to quantitatively assess performance. The severity of myelopathy before surgery was evaluated according to a scoring system proposed by the Japanese Orthopaedic Association for cervical myelopathy (JOA score) in the CSM patients.

RESULTS

In the CSM patients, the 10-s G&R and step test results significantly correlated with the JOA score (P < 0.0001). The number of the 10-s G&R and step tests significantly decreased with age in both groups. There was a difference in the 10-s G&R and step test results between males and females. In the asymptomatic subjects, the number of the 10-s G&R and step tests in the females was less than that in the males. The numbers in the 10-s G&R and step tests were significantly lower in CSM patients than those in asymptomatic subjects in each decade (P < 0.01).

CONCLUSION

The 10-s G&R and 10-s step tests were useful for quantitatively assessing CSM severity, and age and sex differences in results should be considered in screening.

LEVEL OF EVIDENCE

2.

Diabetes as an Independent Predictor for Extended Length of Hospital Stay and Increased Adverse Post-Operative Events in Patients Treated Surgically for Cervical Spondylotic Myelopathy

BACKGROUND

Diabetes as an independent driver of peri-operative outcomes, and whether its severity impacts indications is conflicted in the research. The purpose of this study is to evaluate diabetes as a predictor for postoperative outcomes in cervical spondylotic myelopathy (CSM) patients.

METHODS

A retrospective review was performed of patients treated surgically for CSM (ICD-9 721.1) from 2010-2012 in the prospectively-collected American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Outcome measures were length of stay, and the presence of complications. Diabetic patients were stratified based on whether or not their diabetes was insulin- or non-insulin-dependent.

RESULTS

A total of 5,904 surgical CSM patients were included, 1101 (19%) had diabetes. 722 (65%) were non-insulin-dependent diabetics, and 381 (35%) were insulin-dependent diabetics. Diabetes was found to be an independent predictor of extended LOS (OR: 1.878[2.262-1.559], p<0.001) as well as of developing a complication (OR: 1.666[2.217-1.253], p<0.001) after controlling for associated variables like BMI. Type of diabetes (insulin- vs. non-insulin-dependent) showed little significant difference between the groups (p>0.05), however, patients with insulin-dependent diabetes were associated with an increased incidence of wound complications (p=0.027); severity of diabetes was not associated with any other individual complications.

CONCLUSIONS

Type and severity of diabetes is not a predictor for complication. Diabetes is associated with extended LOS and peri-operative morbidity. Level of evidence: Class 2b. Clinical relevance: Our findings support the view of many spine surgeons, who believe that diabetes has a negative impact on the outcome of surgery for CSM. Our findings support those cohort studies that found an association between diabetes and worst post-operative outcomes following surgical treatment of CSM. These findings lend support to the importance of monitoring preoperative serum glucose levels, as prevention of peri-operative hyperglycemia has been linked to improved postoperative outcomes in spine, joint and colon surgery.

Management of Hyperglycemia and Diabetes in Orthopedic Surgery

An increasing number of orthopedic operations are being carried out in an older population in whom the prevalence of diabetes is dramatically increasing. People having surgery with diabetes and hyperglycemia are at increased risk of post-operative complications. The peri-operative risks have been well demonstrated for cardiac surgery and, more recently, for orthopedic surgery. This paper considers the issues surrounding orthopaedic surgery in patients with diabetes and the significance and management of hyperglycemia in the peri-operative period.

Reoperation rates of anterior cervical discectomy and fusion versus posterior laminoplasty for multilevel cervical degenerative diseases: a population-based cohort study in Taiwan

BACKGROUND CONTEXT

The reoperation (reop) rate is a crucial indicator of the efficacy of an operation; however, studies on the reop rates of anterior cervical discectomy and fusion (ACDF) or posterior laminoplasty (LMP) for treating multilevel cervical degenerative diseases (MCDDs) are scant.

PURPOSE

This study aimed to compare the reop rates and safety of ACDF and LMP for MCDD treatment.

STUDY DESIGN

This is a retrospective population-based cohort study.

PATIENT SAMPLE

Our sample consists of patients who underwent ACDF and LMP treatment.

OUTCOME MEASURES

Reop rate, risk of pneumonia, sepsis, surgery-related complications, and death.

METHODS

A total of 6,605 patients who underwent ACDF and 1,578 patients who underwent LMP for MCDD treatment from 2001 to 2011 were selected from the Taiwan National Health Insurance Research Database. Cox proportional hazard models were performed to compare the clinical outcomes of the patients who underwent ACDF with those of the patients who underwent LMP.

RESULTS

Long-term reop rates (per 100 person-month) were slightly Anterior cervical discectomy and fusion; in the patients who underwent ACDF (0.04 [95% confidence interval, CI: 0.03-0.05]) than in those who underwent LMP (0.06 [95% CI: 0.04-0.08]), with adjusted hazard ratio (HR) of 1.43 (95% CI: 0.96-2.11, p=.08), although short-term reop rates were significantly higher in the LMP group (0.41 [95% CI: 0.33-0.51]) than in the ACDF group (0.09 [95% CI: 0.07-0.11]), with adjusted HR of 4.81 (95% CI: 3.46-6.69, p<.001). Patients who underwent LMP had a lower risk of pneumonia, sepsis, surgery-related complications, and death than did those who underwent ACDF within a year of follow-up. The results after adjustment for all covariates showed that osteoarthritis (adjusted HR=2.07, 95% CI: 1.40-3.06, p<.01) was associated with reop risk in the patients who underwent ACDF, and diabetes (adjusted HR=3.27, 95% CI: 1.12-9.54, p=.03) was associated with reop risk in the patients who underwent LMP.

CONCLUSIONS

There was no significantly higher incidence rate of reop between the patients who underwent LMP and those who underwent ACDF after 1-year follow-up; however, ACDF was associated with a higher rate of 1-year complications and mortality compared with LMP. LMP might be considered as a treatment option for MCDD but could not be appropriate for patients with cervical kyphotic deformity.

Prediction of surgical outcome in compressive cervical myelopathy: A novel clinicoradiological prognostic score

CONTEXT

Preoperative severity of myelopathy, age, and duration of symptoms have been shown to be highly predictive of the outcome in compressive cervical myelopathy (CCM). The role of radiological parameters is still controversial.

AIMS

Define the prognostic factors in CCM and formulate a prognostic score to predict the outcome following surgery in CCM.

SETTINGS AND DESIGN

Retrospective.

MATERIALS AND METHODS

This study included 78 consecutive patients with CCM treated surgically. The modified Japanese Orthopaedic Association (mJOA) scale was used to quantify severity of myelopathy at admission and at 12-month follow-up. The outcome was defined as good if the patient had mJOA score ≥16 and poor if the score was <16. Age, sex, duration of symptoms, comorbidities, intrinsic hand muscle wasting (IHMW), diagnosis, surgical technique, Torg ratio, instability on dynamic radiographs, and magnetic resonance imaging (MRI) signal intensity changes were assessed.

STATISTICS

Statistical Package for the Social Sciences (SPSS) (version 20.0) was used for statistical analysis. The association was assessed amongst variables using logistic regression analysis. Parameters having a statistically significant correlation with the outcome were included in formulating a prognostic score.

RESULTS

Severity of myelopathy, IHMW, age, duration, diabetes, and instability on radiographs were predictive of the outcome with a P value <0.01. Genders, diagnosis, surgical procedure, Torg ratio, and intensity changes on MRI were not significantly related to the outcome. A 8-point scoring system was devised incorporating the significant clinicoradiological parameters, and it was found that nearly all patients (97.82%) with a score below 5 had good outcome and all patients (100%) with a score above 5 had poor outcome. The outcome is difficult to predict with a score of 5.

CONCLUSIONS

Clinical parameters are better predictors of the outcome as compared to radiological findings, following surgery in CCM. A simple scoring system based on clinicoradiological parameters is suggested in this paper to predict the outcome following surgery in cases of CCM.

Diabetes and cervical myelopathy

Diabetes may affect the typical physical findings associated with cervical spondylotic myelopathy, as coexisting diabetic neuropathy may dampen expected hyperreflexia and also produce non-dermatomal extremity numbness. Most large studies of surgically treated diabetic patients with cervical spondylotic myelopathy have focused upon infection rates rather than exploring any differences in the presenting physical signs. We conducted a retrospective study of the pattern of presenting neurological signs and symptoms and of the clinical outcomes in 438 patients surgically treated for cervical spondylotic myelopathy, 79 of whom had diabetes. Compared with non-diabetic patients, those with diabetes were slightly older and had lower preoperative modified Japanese Orthopaedic Association (mJOA) scores. Those with diabetes also had a significantly higher incidence of hyporeflexia and a higher incidence of a positive Babinski sign, but there was no difference in the appearance of the Hoffman sign. The magnitude of mJOA improvement after surgery was comparable. We conclude that diabetes may alter the typical signs and symptoms of cervical spondylotic myelopathy and suggest that knowledge of the differences may aid in securing a prompt and accurate diagnosis.