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Hsueh LL, Yeh YC, Lu ML, Luo CA, Chiu PY, Lai PL, Niu CC. The impact of over-distraction on adjacent segment pathology and cage subsidence in anterior cervical discectomy and fusion. Sci Rep 2023; 13:18493. [PMID: 37898696 PMCID: PMC10613266 DOI: 10.1038/s41598-023-44998-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 10/14/2023] [Indexed: 10/30/2023] Open
Abstract
Over-distraction has been shown to be a risk factor for cage subsidence and postoperative neck pain after anterior cervical discectomy and fusion (ACDF). Biomechanical studies have demonstrated increased adjacent segment intradiscal pressure after ACDF. The purpose of this study is to determine if over-distraction of the index disc has an effect on adjacent segment pathology. A consecutive series of 145 patients who received primary ACDF for cervical degenerative pathologies from January 2010 to December 2017 were retrospectively reviewed. The patients were divided into: (1) Over-distraction group (postoperative-preoperative index disc height ≥ 2 mm), and (2) No-distraction group (postoperative-preoperative index disc height < 2 mm). Outcome measures included radiographic parameters, Japanese Orthopaedic Association (JOA) score, and incidences of cage subsidence, radiological and clinical adjacent segment pathologies (RASP and CASP) were compared between the two groups preoperatively, postoperatively, and at the final follow-up. The two groups were comparable with respect to age, follow-up length, JOA score, incidence of CASP, and radiographic parameters. The Over-distraction group (83 patients; 115 levels) had smaller preoperative index disc height (4.5 vs. 5.2 mm, p < 0.001), but taller postoperative index disc height (7.7 vs. 6.6 mm, p < 0.001) than No-distraction group (62 patients; 90 levels) Furthermore, significantly higher incidences of cage subsidence (47% vs. 31%, p = 0.04) and RASP (any progression: 48% vs. 15%, p < 0.001; progress ≥ 2 grades: 25% vs. 7%, p = 0.001) were observed in the Over-distraction group. The multivariate analysis indicated that over-distraction and multilevel fusion were independent risk factors for RASP. There were no clinical outcome differences between the Over-distraction group and the No-distraction group in ACDF. Over-distraction of the index level of ≥ 2 mm should be avoided because it significantly increases the incidences of RASP and cage subsidence.
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Affiliation(s)
- Lan-Li Hsueh
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou Branch, No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan, ROC
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Branch, No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan, ROC
- College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 333, Taiwan, ROC
| | - Yu-Cheng Yeh
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou Branch, No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan, ROC
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Branch, No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan, ROC
- College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 333, Taiwan, ROC
| | - Meng-Ling Lu
- College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 333, Taiwan, ROC
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Kaohsiung Branch, No. 123, DAPI Rd., Niaosong Dist, Kaohsiung City 833, Taiwan, ROC
| | - Chi-An Luo
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou Branch, No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan, ROC
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Branch, No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan, ROC
- College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 333, Taiwan, ROC
| | - Ping-Yeh Chiu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou Branch, No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan, ROC
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Branch, No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan, ROC
- College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 333, Taiwan, ROC
| | - Po-Liang Lai
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou Branch, No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan, ROC
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Branch, No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan, ROC
- College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 333, Taiwan, ROC
| | - Chi-Chien Niu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkou Branch, No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan, ROC.
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou Branch, No.5, Fuxing St., Guishan Dist., Taoyuan City 333, Taiwan, ROC.
- College of Medicine, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City 333, Taiwan, ROC.
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Luo CA, Lim AS, Lu ML, Chiu PY, Lai PL, Niu CC. The surgical outcome of multilevel anterior cervical discectomy and fusion in myelopathic elderly and younger patients. Sci Rep 2022; 12:4495. [PMID: 35296700 PMCID: PMC8927471 DOI: 10.1038/s41598-022-08243-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 02/28/2022] [Indexed: 11/09/2022] Open
Abstract
The elderly population has an increased risk of degenerative cervical myelopathy due to multilevel disease, causing motor and sensory dysfunctions and a poor quality of life. Multilevel anterior cervical discectomy and fusion (ACDF) is an alternative surgical treatment option, but has a perceived higher risk of complications. The goal of this study is to report the outcome. We retrospectively reviewed patients from 2006 to 2019 undergoing multilevel ACDF for degenerative cervical myelopathy and compared outcomes and complications between elder patients (aged 70 and above) and younger patients (below 70). The patients' comorbidities, and postoperative complications, radiographic parameters such as C2-C7 Cobb angle, C2-C7 sagittal vertical axis, inter-body height of surgical levels and fusion rate were recorded. Japanese Orthopaedic Association (JOA) score and modified Odom's score were collected. Included were 18 elderly (mean age 74, range 70-87) and 45 young patients (mean age 56, range 43-65) with a follow-up of 43.8 and 55.5 months respectively. Three-level ACDF was the most common. The ratios of ASA class III patients were 94.4% and 48.9% (p < 0.001). The Charlson comorbidity indexes were 4.3 ± 1.03 and 2.1 ± 1.11 (p < 0.001). The average lengths of hospital stays were 4.9 and 4.6 days. Eleven patients (61.1%) in the elderly group experienced at least one short-term complication, compared with 16 patients (35.6%) in the younger group (p < 0.05). The middle-term complications were comparable (22.2% and 20.0%). The JOA score, recovery rate and modified Odom score showed comparable result between groups. Despite its extensiveness, multilevel ACDF is feasible for the elder patients with good clinical outcome and fusion rate. When compared to younger cohort, there is a trend of lower preoperative JOA score and recovery rate. The short-term complication rate is higher in the elderly group.
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Affiliation(s)
- Chi-An Luo
- Department of Orthopaedic Surgery, Spine Division, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, 333, Taiwan, ROC.,Department of Orthopaedic Surgery, New Taipei Municipal Tucheng Hospital (Built and Operated By Chang Gung Medical Foundation), No. 6, Sec. 2, Jincheng Rd., Tucheng Dist., New Taipei City, 236, Taiwan, ROC.,Chang Gung University College of Medicine, No.259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 333, Taiwan, ROC
| | - Austin Samuel Lim
- Department of Surgery, Section of Orthopedics, Orthopedic and Spine Surgery, Metropolitan Medical Center, No.1357, Masangkay St, Santa Cruz, 1012, Manila, Metro Manila, Philippines.,Department of Surgery, Section of Orthopedics, Orthopedic and Spine Surgery, Chinese General Hospital, No.286, Blumentritt Rd, Sampaloc, Manila, Metro Manila, Philippines
| | - Meng-Ling Lu
- Department of Orthopaedic Surgery, Spine Division, Kaohsiung Chang Gung Memorial Hospital, No. 123, Dapi Rd., Niaosong Dist., Kaohsiung City, 833, Taiwan, ROC
| | - Ping-Yeh Chiu
- Department of Orthopaedic Surgery, Spine Division, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, 333, Taiwan, ROC.,Chang Gung University College of Medicine, No.259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 333, Taiwan, ROC
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine Division, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, 333, Taiwan, ROC.,Chang Gung University College of Medicine, No.259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 333, Taiwan, ROC
| | - Chi-Chien Niu
- Department of Orthopaedic Surgery, Spine Division, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City, 333, Taiwan, ROC. .,Chang Gung University College of Medicine, No.259, Wenhua 1st Rd, Guishan Dist., Taoyuan City, 333, Taiwan, ROC.
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Luo CA, Lu ML, Kaliya-Perumal AK, Chen LH, Chen WJ, Niu CC. Degenerative cervical myelopathy presenting as subjective lower limb weakness could be a trap towards misdiagnosis. Sci Rep 2020; 10:21188. [PMID: 33273536 PMCID: PMC7712653 DOI: 10.1038/s41598-020-78139-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 11/09/2020] [Indexed: 11/17/2022] Open
Abstract
When patients presenting with subjective lower limb weakness (SLLW) are encountered, it is natural to suspect a lumbar pathology and proceed with related clinical examination, investigations and management. However, SLLW could be a sign of degenerative cervical myelopathy (DCM) due to an evolving cord compression. In such circumstances, if symptoms are not correlated to myelopathy at the earliest, there could be potential complications over time. In this study, we intend to analyse the outcomes after surgical management of the cervical or thoracic cord compression in patients with SLLW. Retrospectively, patients who presented to our center during the years 2010–2016 with sole complaint of bilateral SLLW but radiologically diagnosed to have a solitary cervical or thoracic stenosis, or tandem spinal stenosis and underwent surgical decompression procedures were selected. Their clinical presentation was categorised into three types, myelopathy was graded using Nurick’s grading and JOA scoring; in addition, their lower limb functional status was assessed using the lower extremity functional scale (LEFS). Functional recovery following surgery was assessed at 6 weeks, 3 months, 6 months, one year, and two years. Selected patients (n = 24; Age, 56.4 ± 10.1 years; range 32–78 years) had SLLW for a period of 6.4 ± 3.2 months (range 2–13 months). Their preoperative JOA score was 11.3 ± 1.8 (range 7–15), and LEFS was 34.4 ± 7.7 (range 20–46). Radiological evidence of a solitary cervical lesion and tandem spinal stenosis was found in 6 and 18 patients respectively. Patients gradually recovered after surgical decompression with LEFS 59.8 ± 2.7 (range 56–65) at 1 year and JOA score 13.6 ± 2.7 (range − 17 to 100) at 2 years. The recovery rate at final follow up was 47.5%. Our results indicate the importance of clinically suspecting SLLW as an early non-specific sign of DCM to avoid misdiagnosis, especially in patients without conventional upper motor neuron signs. In such cases, surgical management of the cord compression resulted in significant functional recovery and halted the progression towards permanent disability.
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Affiliation(s)
- Chi-An Luo
- Department of Orthopaedic Surgery, New Taipei Municipal TuCheng Hospital, New Taipei, 236, Taiwan, ROC.,Bone and Joint Research Center, Linkou Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan, ROC
| | - Meng-Ling Lu
- Bone and Joint Research Center, Linkou Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan, ROC.,Department of Orthopaedic Surgery, Spine Division, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, 833, Taiwan, ROC
| | - Arun-Kumar Kaliya-Perumal
- Bone and Joint Research Center, Linkou Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan, ROC.,Department of Orthopaedic Surgery, Spine Division, Chang Gung Memorial Hospital at Linkou, 5, Fuxing Street, Taoyuan, Guishan, 333, Taiwan, ROC.,Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, 603319, India
| | - Lih-Huei Chen
- Department of Orthopaedic Surgery, Spine Division, Chang Gung Memorial Hospital at Linkou, 5, Fuxing Street, Taoyuan, Guishan, 333, Taiwan, ROC
| | - Wen-Jer Chen
- Department of Orthopaedic Surgery, Chung Shan Hospital, Taipei, 106, Taiwan, ROC
| | - Chi-Chien Niu
- Bone and Joint Research Center, Linkou Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan, ROC. .,Department of Orthopaedic Surgery, Spine Division, Chang Gung Memorial Hospital at Linkou, 5, Fuxing Street, Taoyuan, Guishan, 333, Taiwan, ROC.
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Kaliya-Perumal AK, Luo CA, Yeh YC, Tsai YF, Chen MJW, Tsai TT. RELIABILITY OF THE MICHIGAN STATE UNIVERSITY (MSU) CLASSIFICATION OF LUMBAR DISC HERNIATION. Acta Ortop Bras 2019; 26:411-414. [PMID: 30774517 PMCID: PMC6362681 DOI: 10.1590/1413-785220182606201444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective: The Michigan State University (MSU) classification of lumbar disc herniation (LDH) is periodically used by various authors to classify disc herniation. We assessed the reliability of this classification system among orthopedic residents at our institute. Methods: Fifty T2 axial-cut magnetic resonance images (MRI) corresponding to the level of maximal disc herniation from patients diagnosed with a single LDH were selected and distributed to six orthopedic residents. All six residents gave a specific rating for each image based on the MSU classification; in addition, three residents gave ratings on two different occasions. The degree of agreement among residents was analyzed by calculating inter-observer and intra-observer reliability using the Kappa statistic. Results: The inter-observer reliability among the six residents calculated as the Fleiss’ Kappa was 0.422, which indicates moderate reliability. The intra-observer reliability of three selected residents calculated by Cohen's Kappa was 0.750, 0.772, and 0.859, which indicates substantial to almost perfect reliability. Variations in ratings were frequent in images portraying a broad-based disc herniation with spinal canal stenosis. Conclusion: Our findings demonstrate moderate homogeneity of ratings given by residents; however, test-retest results proved the ratings to be consistent. Level of Evidence II, Diagnostic studies - investigating a diagnostic examination.
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Affiliation(s)
- Arun-Kumar Kaliya-Perumal
- Chang Gung Memorial Hospital and University College of Medicine, Taiwan; Melmaruvathur Adhiparasakthi institute of Medical Sciences and Research, India
| | - Chi-An Luo
- Chang Gung Memorial Hospital and University College of Medicine, Taiwan
| | - Yu-Cheng Yeh
- Chang Gung Memorial Hospital and University College of Medicine, Taiwan
| | - Yi-Fang Tsai
- Chang Gung Memorial Hospital and University College of Medicine, Taiwan
| | | | - Tsung-Ting Tsai
- Chang Gung Memorial Hospital and University College of Medicine, Taiwan
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Luo CA, Tsai TT, Lu ML, Hsieh MK, Lai PL, Fu TS, Chen WJ, Chen LH, Niu CC. Factors related to post surgical neurologic improvement for cervical spine infection. Biomed J 2018; 41:306-313. [PMID: 30580794 PMCID: PMC6306300 DOI: 10.1016/j.bj.2018.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 07/27/2017] [Accepted: 07/31/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cervical spine infections are uncommon but potentially dangerous, having the highest rate of neurological compromise and resulting disability. However, the factors related to surgical success is multiple yet unclear. METHODS We retrospectively reviewed the medical records of 27 patients (16 men and 11 women) with cervical spine infection who underwent surgical treatment at Chang Gung Memorial Hospital, Linkou branch, between 2001 and 2014. The neurological status, by Frankel classification, was recorded preoperatively and at discharge. Group X had neurologic improvement of at least 1 grade, group Y had unchanged neurologic status, and group Z showed deterioration. We recorded the patient demographic data, presenting symptoms and signs, interval from admission to surgery, surgical procedure, laboratory data, perioperative antibiotic course, pathogens identified, coexisting medical disease, concomitant nonspinal infection, and clinical outcomes. We intended to evaluate the different characteristics of patients who improved neurologically after treatment. RESULTS The mean age of our cohort was 56.6 years. Anterior cervical discectomy and fusion was the most commonly performed surgical procedure (74.1%). The Frankel neurological status improved in 70.4% (group X, n = 19) and unchanged in 29.6% (group Y, n = 8). No patients worsened. Motor weakness was most common (96.3%) neurological deficit, followed by sensory abnormalities (37.0%), and bowel/urine incontinence (33.3%). The main difference in presentation between group X and group Y was neck pain (100% vs. 75.0%; p = .02), not fever. Group X had a shorter preoperative antibiotic course (p = .004), interval from admission to operation (p = .02), and hospital stay (p = .01). CONCLUSION Clinicians should be more suspicious in patients who present with neck pain and any neurological involvement even in those without fever while establishing early diagnosis. Earlier operative treatment in group X result in better neurologic recovery and shorter hospital stay due to disease improvement.
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Affiliation(s)
- Chi-An Luo
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Meng-Ling Lu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Ming-Kai Hsieh
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Tsai-Sheng Fu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Wen-Jer Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Lih-Huei Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Chi-Chien Niu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
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Luo CA, Kaliya-Perumal AK, Lu ML, Chen LH, Chen WJ, Niu CC. Staged surgery for tandem cervical and lumbar spinal stenosis: Which should be treated first? Eur Spine J 2018; 28:61-68. [DOI: 10.1007/s00586-018-5795-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/25/2018] [Accepted: 10/12/2018] [Indexed: 11/28/2022]
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Kaliya-Perumal AK, Ariputhiran-Tamilselvam SK, Luo CA, Thiagarajan S, Selvam U, Sumathi-Edirolimanian RP. Revalidating Pfirrmann's Magnetic Resonance Image-Based Grading of Lumbar Nerve Root Compromise by Calculating Reliability among Orthopaedic Residents. Clin Orthop Surg 2018; 10:210-215. [PMID: 29854345 PMCID: PMC5964270 DOI: 10.4055/cios.2018.10.2.210] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 03/15/2018] [Indexed: 12/26/2022] Open
Abstract
Background Intervertebral disc herniations lead to subsequent compromise of the nerve root. The root can either have a mere contact with the disc material or be pushed aside or compressed. This was earlier graded by Pfirrmann and colleagues. We intend to revalidate this grading system by performing a reliability analysis among orthopaedic residents. Methods Fifty axial cut magnetic resonance (MR) images of the affected lumbar disc level that belonged to different patients (age, 37.8 ± 10.4 years; 33 males and 17 females) were chosen and given to five orthopaedic residents for grading according to the Pfirrmann's MR image-based grading of lumbar nerve root compromise. Responses were received in the form of categorical variables and reliability was assessed. Results On doing percentage statistics, we found that 14 images had 100% agreement, 22 had 80% agreement and 14 had 60% agreement. We inferred an overall agreement of 80% ± 15.1%. In addition, interrater reliability was determined by calculating the Fleiss' kappa, which was found to be 0.521, signifying moderate agreement. Intrarater reliability was determined by calculating Cohen's kappa, which was found to be 0.696, signifying substantial agreement. Conclusions Our residents took only a short time to learn and reproduce this grading system as ratings that proved to be moderately reliable. Even though the value of kappa was slightly lower, reliability was similar to that of the original authors. We think that this grading system can be adopted in day-to-day practice by framing appropriate rules to interpret MR images where the nerve roots are not visible.
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Affiliation(s)
- Arun-Kumar Kaliya-Perumal
- Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Affiliated to the Tamil Nadu Dr MGR Medical University, Tamil Nadu, India
| | - Senthil-Kumar Ariputhiran-Tamilselvam
- Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Affiliated to the Tamil Nadu Dr MGR Medical University, Tamil Nadu, India
| | - Chi-An Luo
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Sivaharivelan Thiagarajan
- Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Affiliated to the Tamil Nadu Dr MGR Medical University, Tamil Nadu, India
| | - Udhayakumar Selvam
- Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Affiliated to the Tamil Nadu Dr MGR Medical University, Tamil Nadu, India
| | - Raj-Prabhakar Sumathi-Edirolimanian
- Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Affiliated to the Tamil Nadu Dr MGR Medical University, Tamil Nadu, India
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Abstract
BACKGROUND Calcaneal lengthening is used to correct symptomatic planovalgus foot deformity, but outcomes have been less satisfactory in children with cerebral palsy. This study aimed to define limits of calcaneal lengthening by analyzing the risk factors for undercorrection of deformity. METHODS We retrospectively reviewed 20 cases of children with cerebral palsy who underwent calcaneal lengthening of 30 planovalgus feet at a mean age of 11.9 years. Foot deformities were evaluated by the anteroposterior talo-first metatarsal angle (normal, 10 ± 7.0 degrees), lateral talo-first metatarsal angle (normal, 13 ± 7.5 degrees), and lateral calcaneal pitch angle (normal, 17 ± 6.0 degrees) on standing foot radiographs. Among these parameters, a corrected foot was defined as 2 or 3 parameters being corrected to within a normal range, and an undercorrected foot was only 1 or no parameter being corrected to within a normal range. Factors were compared between the corrected group and undercorrected group for significant predictors, and cutoff values of predictors were calculated for use as a clinical guideline. RESULTS Seventeen planovalgus feet were corrected satisfactorily by calcaneal lengthening, while the other 13 feet were undercorrected. Undercorrected feet had a greater preoperative anteroposterior talonavicular angle (33.7 vs 22.8 degrees, P = .001) and a smaller lateral calcaneal pitch (-1.7 vs 5.6 degrees, P = .03). A talonavicular angle of more than 24 degrees and calcaneal pitch less than -5 degrees were identified as cutoff values using a receiver operating characteristic curve. The predicted probability of undercorrection was 100% (9/9 feet) for 2 positive predictors, 50% (8/16 feet) for 1 positive predictor, and 0 (0/5 feet) for zero predictors. CONCLUSION A talonavicular lateral subluxation of more than 24 degrees on the anteroposterior radiograph and a calcaneal pitch angle less than -5 degrees on the lateral radiograph were 2 independent predictors that could be used to identify a planovalgus deformity that would be beyond the corrective capacity of calcaneal lengthening to restore normal alignment. Level of Evidence Retrospective case control study, level III.
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Affiliation(s)
- Chi-An Luo
- 1 Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Kai Kao
- 1 Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Chun Lee
- 1 Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Wen-E Yang
- 1 Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Hsieh Chang
- 1 Department of Pediatric Orthopedics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Kaliya-Perumal AK, Yeh YC, Luo CA, Joey-Tan KY. Assessment of Anteroposterior Subpedicular Approach and Oblique Scotty Dog Subpedicular Approach for Selective Nerve Root Block. Clin Orthop Surg 2017; 9:71-76. [PMID: 28261430 PMCID: PMC5334030 DOI: 10.4055/cios.2017.9.1.71] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 12/13/2016] [Indexed: 11/06/2022] Open
Abstract
Background The technique used to administer a selective nerve root block (SNRB) varies depending on individual expertise. Both the anteroposterior (AP) subpedicular approach and oblique Scotty dog subpedicular approach are widely practiced. However, the literature does not provide a clear consensus regarding which approach is more suitable. Hence, we decided to analyse the procedural parameters and clinical outcomes following SNRBs using these two approaches. Methods Patients diagnosed with a single lumbar herniated intervertebral disc (HIVD) refractory to conservative management but not willing for immediate surgery were selected for a prospective nonrandomized comparative study. An SNRB was administered as a therapeutic alternative using the AP subpedicular approach in one group (n = 25; mean age, 45 ± 5.4 years) and the oblique Scotty dog subpedicular approach in the other group (n = 22; mean age, 43.8 ± 4.7 years). Results were compared in terms of the duration of the procedure, the number of C-arm exposures, accuracy, pain relief, functional outcome and the duration of relief. Results Our results suggest that the oblique Scotty dog subpedicular approach took a significantly longer duration (p = 0.02) and a greater number of C-arm exposures (p = 0.001). But, its accuracy of needle placement was 95.5% compared to only 72% using the AP subpedicular approach (p = 0.03). There was no significant difference in terms of clinical outcomes between these approaches. Conclusions The AP subpedicular approach was simple and facile, but the oblique Scotty dog subpedicular approach was more accurate. However, a brief window period of pain relief was achieved irrespective of the approaching technique used.
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Affiliation(s)
- Arun-Kumar Kaliya-Perumal
- Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, India
| | - Yu-Cheng Yeh
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chi-An Luo
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Kaliya-Perumal AK, Lu ML, Luo CA, Tsai TT, Lai PL, Chen LH, Chen WJ, Niu CC. Retrospective radiological outcome analysis following teriparatide use in elderly patients undergoing multilevel instrumented lumbar fusion surgery. Medicine (Baltimore) 2017; 96:e5996. [PMID: 28151894 PMCID: PMC5293457 DOI: 10.1097/md.0000000000005996] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Elderly patients with chronic nonresolving symptoms due to degenerative spine pathologies are prone to have poor surgical outcomes and hardware-related complications, especially following multilevel instrumented lumbar fusion surgeries. With intention of analyzing if teriparatide can be an effective adjunct therapy to surgical management, radiological outcomes are studied. Sixty-two elderly patients were divided into 2 similar groups. Group 1 (n = 30; mean age = 69.83 years; fusion levels = 137; screws = 269) had taken teriparatide (20 mcg SC injection, once daily) for a duration of 7.4 ± 2.4 months following surgery and Group 2 (n = 32; mean age = 70.38 years; fusion levels = 144; screws = 283) did not take teriparatide. Radiological evaluation was done to determine the state of postero lateral fusion mass and to investigate the incidence of pedicle screw loosening at 1-year follow-up. Unilateral or bilateral bridging bone formation across the transverse process of adjacent vertebras showing continuous trabeculation suggestive of solid fusion was obtained in 66.7% patients in the teriparatide group and 50% patients in the control group (P = 0.20). 13.4% of the total no. of screws showed signs of loosening in the teriparatide group, compared to 24.4% in the control group (P = 0.001). Percentage of patients achieving solid fusion following teriparatide use was found to be more than that of the control group. This difference may have clinical importance but was not statistically significant. However, teriparatide use was more significantly influential in reducing the incidence of subsequent pedicle screw loosening.
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Affiliation(s)
- Arun-Kumar Kaliya-Perumal
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Orthopaedic Surgery, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, India
| | - Meng-Ling Lu
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-An Luo
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tsung-Ting Tsai
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Po-Liang Lai
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Lih-Huei Chen
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Jer Chen
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Chien Niu
- Department of Orthopaedic Surgery, Spine Division, Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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