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Yi-Hsuan Kuo, Chao-Hung Kuo, Hsuan-Kan Chang, Tsung-Hsi Tu, Li-Yu Fay, Chih-Chang Chang, Henrich Cheng, Ching-Lan Wu, Jiing-Feng Lirng, Jau-Ching Wu and Wen-Cheng Huang

OBJECTIVE

Cigarette smoking has been known to increase the risk of pseudarthrosis in spinal fusion. However, there is a paucity of data on the effects of smoking in dynamic stabilization following lumbar spine surgery. This study aimed to investigate the clinical outcomes and the incidence of screw loosening among patients who smoked.

METHODS

Consecutive patients who had lumbar spondylosis, recurrent disc herniations, or low-grade spondylolisthesis that was treated with 1- or 2-level surgical decompression and pedicle screw–based Dynesys dynamic stabilization (DDS) were retrospectively reviewed. Patients who did not complete the minimum 2 years of radiological and clinical evaluations were excluded. All screw loosening was determined by both radiographs and CT scans. Patient-reported outcomes, including visual analog scale (VAS) scores of back and leg pain, Japanese Orthopaedic Association (JOA) scores, and Oswestry Disability Index (ODI), were analyzed. Patients were grouped by smoking versus nonsmoking, and loosening versus intact screws, respectively. All radiological and clinical outcomes were compared between the groups.

RESULTS

A total of 306 patients (140 women), with a mean age of 60.2 ± 12.5 years, were analyzed during an average follow-up of 44 months. There were 34 smokers (9 women) and 272 nonsmokers (131 women, 48.2% more than the 26.5% of smokers, p = 0.017). Postoperatively, all the clinical outcomes improved (e.g., VAS back and leg pain, JOA scores, and ODI, all p < 0.001). The overall rate of screw loosening was 23.2% (71 patients), and patients who had loosened screws were older (61.7 ± 9.6 years vs 59.8 ± 13.2 years, p = 0.003) and had higher rates of diabetes mellitus (33.8% vs 21.7%, p = 0.038) than those who had intact DDS screws. Although the patients who smoked had similar clinical improvement (even better VAS scores in their legs, p = 0.038) and a nonsignificantly lower rate of screw loosening (17.7% and 23.9%, p = 0.416), the chances of secondary surgery for adjacent segment disease (ASD) were higher than for the nonsmokers (11.8% vs 1.5%, p < 0.001).

CONCLUSIONS

Smoking had no adverse effects on the improvements of clinical outcomes in the pedicle screw–based DDS surgery. For smokers, the rate of screw loosening trended lower (without significance), but the chances of secondary surgery for ASD were higher than for the nonsmoking patients. However, the optimal surgical strategy to stabilize the lumbar spine of smoking patients requires future investigation.

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Zoher Ghogawala, Shekar Kurpad, Asdrubal Falavigna, Michael W. Groff, Daniel M. Sciubba, Jau-Ching Wu, Paul Park, Sigurd Berven, Daniel J. Hoh, Erica F. Bisson, Michael P. Steinmetz, Marjorie C. Wang, Dean Chou, Charles A. Sansur, Justin S. Smith and Luis M. Tumialán

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Oliver Daniel Mowforth, Michelle Louise Starkey, Mark Reinhard Kotter and Benjamin Marshall Davies

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Yu-Chun Chen, Chao-Hung Kuo, Chieh-Ming Cheng and Jau-Ching Wu

OBJECTIVE

Cervical spondylotic myelopathy (CSM) has become a prevalent cause of spinal cord dysfunction among the aging population worldwide. Although great strides have been made in spine surgery in past decades, the optimal timing and surgical strategy to treat CSM have remained controversial. In this article the authors aimed to analyze the current trends in studies of CSM and to summarize the recent advances of surgical techniques in its treatment.

METHODS

The PubMed database was searched using the keywords pertaining to CSM in human studies that were published between 1975 and 2018. Analyses of both the bibliometrics and contents, including the types of papers, authors, affiliations and countries, number of patients, and the surgical approaches were conducted. A systematic review of the literature was also performed with emphasis on the diagnosis and treatment of mild CSM.

RESULTS

A total of 1008 papers published during the span of 44 years were analyzed. These CSM studies mainly focused on the natural history, diagnosis, and treatment, and only a few prospective randomized trials were reported. For the authors and affiliations, there was a shift of clustering of papers toward Asian countries in the past decades. Regarding the treatment for CSM, there was an exponential growth of surgical series published, and there was a trend toward slightly more anterior than posterior approaches through the past decade. Patients with CSM had increased risks of neurological deterioration or spinal cord injury with nonoperative management. Because surgery might reduce the risks, and early surgery was likely to be correlated with better outcomes, there was a trend toward attention to mildly symptomatic CSM.

CONCLUSIONS

There is emerging enthusiasm for research on CSM worldwide, with more publications originating in Asian countries over the past few decades. The surgical management of CSM is evolving continuously toward early and anterior approaches. More prospective investigations on the optimal timing and choices of surgery are therefore needed.

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Li-Yu Fay, Wen-Cheng Huang, Chih-Chang Chang, Hsuan-Kan Chang, Tzu-Yun Tsai, Tsung-Hsi Tu, Ching-Lan Wu, Henrich Cheng and Jau-Ching Wu

OBJECTIVE

The pedicle screw–based Dynesys dynamic stabilization (DDS) has reportedly become a surgical option for lumbar spondylosis and spondylolisthesis. However, it is still unclear whether the dynamic construct remains mobile or eventually fuses. The aim of this study was to investigate the incidence of unintended facet arthrodesis after DDS and its association with spondylolisthesis.

METHODS

This retrospective study was designed to review 105 consecutive patients with 1- or 2-level lumbar spondylosis who were treated with DDS surgery. The patients were then divided into 2 groups according to preexisting spondylolisthesis or not. All patients underwent laminectomies, foraminotomies, and DDS. The clinical outcomes were measured using visual analog scale (VAS) scores for back and leg pain, Japanese Orthopaedic Association (JOA) scores, and Oswestry Disability Index (ODI) scores. All medical records, including pre- and postoperative radiographs, CT scans, and MR images, were also reviewed and compared.

RESULTS

A total of 96 patients who completed the postoperative follow-up for more than 30 months were analyzed. The mean age was 64.1 ± 12.9 years, and the mean follow-up duration was 46.3 ± 12.0 months. There were 45 patients in the spondylolisthesis group and 51 patients in the nonspondylolisthesis group. The overall prevalence rate of unintended facet fusion was 52.1% in the series of DDS. Patients with spondylolisthesis were older (67.8 vs 60.8 years, p = 0.007) and had a higher incidence rate of facet arthrodesis (75.6% vs 31.4%, p < 0.001) than patients without spondylolisthesis. Patients who had spondylolisthesis or were older than 65 years were more likely to have facet arthrodesis (OR 6.76 and 4.82, respectively). There were no significant differences in clinical outcomes, including VAS back and leg pain, ODI, and JOA scores between the 2 groups. Furthermore, regardless of whether or not unintended facet arthrodesis occurred, all patients experienced significant improvement (all p < 0.05) in the clinical evaluations.

CONCLUSIONS

During the mean follow-up of almost 4 years, the prevalence of unintended facet arthrodesis was 52.1% in patients who underwent DDS. Although the clinical outcomes were not affected, elderly patients with spondylolisthesis might have a greater chance of facet fusion. This could be a cause of the limited range of motion at the index levels long after DDS.

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Tsung-Hsi Tu, Chao-Hung Kuo, Wen-Cheng Huang, Li-Yu Fay, Henrich Cheng and Jau-Ching Wu

OBJECTIVE

Cigarette smoking can adversely affect bone fusion in patients who undergo anterior cervical discectomy and fusion. However, there is a paucity of data on smoking among patients who have undergone cervical disc arthroplasty (CDA). The present study aimed to compare the clinical and radiological outcomes of smokers to those of nonsmokers following CDA.

METHODS

The authors retrospectively reviewed the records of consecutive patients who had undergone 1- or 2-level CDA for cervical disc herniation or spondylosis and had a minimum 2-year follow-up. All patients were grouped into a smoking group, which consisted of those who had consumed cigarettes within 6 months prior to the CDA surgery, or a nonsmoking group, which consisted of those who had not consumed cigarettes at all or within 6 months of the CDA. Clinical outcomes were evaluated according to the visual analog scale for neck and arm pain, Neck Disability Index, Japanese Orthopaedic Association Scale, and Nurick Scale at each time point of evaluation. Radiological outcomes were assessed using radiographs and CT for multiple parameters, including segmental range of motion (ROM), neutral lordotic curve, and presence of heterotopic ossification (HO).

RESULTS

A total of 109 patients completed at least 2 years of follow-up and were analyzed (mean follow-up 42.3 months). There were 89 patients in the nonsmoking group and 20 in the smoking group. The latter group was younger and predominantly male (both p < 0.05) compared to the nonsmoking group. The two groups had similar improvements in all clinical outcomes after CDA compared to preoperatively. Radiological evaluations were also very similar between the two groups, except for two factors. The smoking group had well-preserved segmental ROM after CDA at an average of 8.1° (both pre- and postoperation). However, while the nonsmoking group remained mobile, segmental ROM decreased significantly (8.2° to 6.9°, p < 0.05) after CDA. There was a trend toward more HO development in the nonsmoking group than in the smoking group, but the difference was without significance (59.6% vs 50.0%, p = 0.43).

CONCLUSIONS

During an average 3.5 years of follow-up after 1- and 2-level CDA, cigarette smokers and nonsmokers had similar improvements in clinical outcomes. Moreover, segmental mobility was slightly better preserved in smokers. Since smoking status did not negatively impact outcomes, CDA may be a reasonable option for selected patients who have smoked.

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Chih-Chang Chang, Wen-Cheng Huang, Tsung-Hsi Tu, Peng-Yuan Chang, Li-Yu Fay, Jau-Ching Wu and Henrich Cheng

OBJECTIVE

To avoid jeopardizing an aberrant vertebral artery, there are three common options in placing a C2 screw, including pedicle, pars, and translaminar screws. Although biomechanical studies have demonstrated similar strength among these C2 screws in vitro, there are limited clinical data to address their differences in vivo. When different screws were placed in each side, few reports have compared the outcomes. The present study aimed to evaluate these multiple combinations of C2 screws.

METHODS

Consecutive adult patients who underwent posterior atlantoaxial (AA) fixation were retrospectively reviewed. Every patient uniformly had bilateral C1 lateral mass screws in conjunction with 2 C2 screws (1 C2 screw on each side chosen among the three options: pedicle, pars, or translaminar screws, based on individualized anatomical consideration). These patients were then grouped according to the different combinations of C2 screws for comparison of the outcomes.

RESULTS

A total of 63 patients were analyzed, with a mean follow-up of 34.3 months. There were five kinds of construct combinations of the C2 screws: 2 pedicle screws (the Ped-Ped group, n = 24), 2 translaminar screws (the La-La group, n = 7), 2 pars screws (the Pars-Pars group, n = 6), 1 pedicle and 1 pars screw (the Ped-Pars group, n = 7), and 1 pedicle and 1 translaminar screw (the Ped-La group, n = 19). The rate of successful fixation in each of the groups was 100%, 57.1%, 100%, 100%, and 78.9% (Ped-Ped, La-La, Par-Par, Ped-Par, and Ped-La, respectively). The patients who had no translaminar screw had a higher rate of success than those who had 1 or 2 translaminar screws (100% vs 73.1%, p = 0.0009). Among the 5 kinds of construct combinations, 2 C2 pedicle screws (the Ped-Ped group) had higher rates of success than 1 C2 pedicle and 1 C2 translaminar screw (the Ped-La group, p = 0.018). Overall, the rate of successful fixation was 87.3% (55/63). There were 7 patients (4 in the Ped-La group and 3 in the La-La group) who lost fixation/reduction, and they all had at least 1 translaminar screw.

CONCLUSIONS

In AA fixation, C2 pedicle or pars screws or a combination of both provided very high success rates. Involvement of 1 or 2 C2 translaminar screws in the construct significantly lowered success rates. Therefore, a C2 pars screw is recommended over a translaminar screw.

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Chao-Hung Kuo, Wen-Cheng Huang, Jau-Ching Wu, Tsung-Hsi Tu, Li-Yu Fay, Ching-Lan Wu and Henrich Cheng

OBJECTIVE

Pedicle screw–based dynamic stabilization has been an alternative to conventional lumbar fusion for the surgical management of low-grade spondylolisthesis. However, the true effect of dynamic stabilization on adjacent-segment degeneration (ASD) remains undetermined. Authors of this study aimed to investigate the incidence of ASD and to compare the clinical outcomes of dynamic stabilization and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

METHODS

The records of consecutive patients with Meyerding grade I degenerative spondylolisthesis who had undergone surgical management at L4–5 in the period from 2007 to 2014 were retrospectively reviewed. Patients were divided into two groups according to the surgery performed: Dynesys dynamic stabilization (DDS) group and MI-TLIF group. Pre- and postoperative radiological evaluations, including radiography, CT, and MRI studies, were compared. Adjacent discs were evaluated using 4 radiological parameters: instability (antero- or retrolisthesis), disc degeneration (Pfirrmann classification), endplate degeneration (Modic classification), and range of motion (ROM). Clinical outcomes, measured with the visual analog scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI), and the Japanese Orthopaedic Association (JOA) scores, were also compared.

RESULTS

A total of 79 patients with L4–5 degenerative spondylolisthesis were included in the analysis. During a mean follow-up of 35.2 months (range 24–89 months), there were 56 patients in the DDS group and 23 in the MI-TLIF group. Prior to surgery, both groups were very similar in demographic, radiological, and clinical data. Postoperation, both groups had similarly significant improvement in clinical outcomes (VAS, ODI, and JOA scores) at each time point of evaluation. There was a lower chance of disc degeneration (Pfirrmann classification) of the adjacent discs in the DDS group than in the MI-TLIF group (17% vs 37%, p = 0.01). However, the DDS and MI-TLIF groups had similar rates of instability (15.2% vs 17.4%, respectively, p = 0.92) and endplate degeneration (1.8% vs 6.5%, p = 0.30) at the cranial (L3–4) and caudal (L5–S1) adjacent levels after surgery. The mean ROM in the cranial and caudal levels was also similar in the two groups. None of the patients required secondary surgery for any ASD (defined by radiological criteria).

CONCLUSIONS

The clinical improvements after DDS were similar to those following MI-TLIF for L4–5 Meyerding grade I degenerative spondylolisthesis at 3 years postoperation. According to radiological evaluations, there was a lower chance of disc degeneration in the adjacent levels of the patients who had undergone DDS. However, other radiological signs of ASD, including instability, endplate degeneration, and ROM, were similar between the two groups. Although none of the patients in the present series required secondary surgery, a longer follow-up and a larger number of patients would be necessary to corroborate the protective effect of DDS against ASD.