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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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Zhiming Tu, Yawei Li, Lei Li, Guohua Lv and Bing Wang

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

OBJECTIVE

Cervical disc arthroplasty (CDA) has been demonstrated to be as safe and effective as anterior cervical discectomy and fusion (ACDF) in the management of 1- and 2-level degenerative disc disease (DDD). However, there has been a lack of data to address the fundamental discrepancy between the two surgeries (CDA vs ACDF), and preservation versus elimination of motion, in the management of cervical myelopathy associated with congenital cervical stenosis (CCS). Although younger patients tend to benefit more from motion preservation, it is uncertain if CCS caused by multilevel DDD can be treated safely with CDA.

METHODS

Consecutive patients who underwent 3-level anterior cervical discectomy were retrospectively reviewed. Inclusion criteria were age less than 50 years, CCS (Pavlov ratio ≤ 0.82), symptomatic myelopathy correlated with DDD, and stenosis limited to 3 levels of the subaxial cervical (C3–7) spine. Exclusion criteria were ossification of the posterior longitudinal ligament, previous posterior decompression surgery (e.g., laminoplasty or laminectomy), osteoporosis, previous trauma, or other rheumatic diseases that might have caused the cervical myelopathy. All these patients who underwent 3-level discectomy were divided into 2 groups according to the strategies of management: preservation or elimination of motion (the hybrid-CDA group and the ACDF group). The hybrid-CDA group underwent 2-level CDA plus 1-level ACDF, whereas the ACDF group underwent 3-level ACDF. Clinical assessment was measured by the visual analog scales (VAS) for neck and arm pain, Japanese Orthopaedic Association (JOA) scores, and Nurick grades. Radiographic outcomes were measured using dynamic radiographs for evaluation of range of motion (ROM).

RESULTS

Thirty-seven patients, with a mean (± SD) age of 44.57 ± 5.10 years, were included in the final analysis. There was a male predominance in this series (78.4%, 29 male patients), and the mean follow-up duration was 2.37 ± 1.60 years. There were 20 patients in the hybrid-CDA group, and 17 in the ACDF group. Both groups demonstrated similar clinical improvement at 2 years' follow-up. These patients with 3-level stenosis experienced significant improvement after either type of surgery (hybrid-CDA and ACDF). There were no significant differences between the 2 groups at each of the follow-up visits postoperatively. The preoperative ROM over the operated subaxial levels was similar between both groups (21.9° vs 21.67°; p = 0.94). Postoperatively, the hybrid-CDA group had significantly greater ROM (10.65° vs 2.19°; p < 0.001) than the ACDF group. Complications, adverse events, and reoperations in both groups were similarly low.

CONCLUSIONS

Hybrid-CDA yielded similar clinical improvement to 3-level ACDF in patients with myelopathy caused by CCS. In this relatively young group of patients, hybrid-CDA demonstrated significantly more ROM than 3-level ACDF without adjacent-segment disease (ASD) at 2 years' follow-up. Therefore, hybrid-CDA appears to be an acceptable option in the management of CCS. The strategy of motion preservation yielded similar improvements of cervical myelopathy to motion elimination (i.e., ACDF) in patients with CCS, while the theoretical benefit of reducing ASD required further validation.

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Michael Y. Wang, Peng-Yuan Chang and Jay Grossman

OBJECTIVE

Over the past decade, Enhancing Recovery After Surgery (ERAS) programs have been implemented throughout the world across multiple surgical disciplines. However, to date no spinal surgery equivalent has been described. In this report the authors review the development and implementation of a “fast track” surgical approach for lumbar fusion.

METHODS

The first 42 consecutive cases in which patients were treated with the new surgical procedure were reviewed. A combination of endoscopic decompression, expandable cage deployment, and percutaneous screw placement were performed with liposomal bupivacaine anesthesia to allow the surgery to be performed without general endotracheal anesthesia.

RESULTS

In all cases the surgical procedure was performed successfully without conversion to an open operation. The patients' mean age (± SD) was 66.1 ± 11.7 years, the male/female ratio was 20:22, and a total of 47 levels were treated. The mean operative time was 94.6 ± 22.4 minutes, the mean intraoperative blood loss was 66 ± 30 ml, and the mean hospital length of stay was 1.29 ± 0.9 nights. Early follow-up showed a significant improvement in the mean Oswestry Disability Index score (from 40 ± 13 to 17 ± 11, p = 0.0001). Return to the operating room was required in 2 cases due to infection and in 1 case due to cage displacement. An iterative quality improvement program demonstrated areas of improvement, including steps to minimize infection, improve postoperative analgesia, and reduce cage osteolysis.

CONCLUSIONS

ERAS programs for improving spinal fusion surgery are possible and necessary. This report demonstrates a first foray to apply these principles through 1) a patient-focused approach, 2) reducing the stress of the operation, and 3) an iterative improvement process.

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

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

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

OBJECTIVE

Many reports have successfully demonstrated that cervical disc arthroplasty (CDA) can preserve range of motion after 1- or 2-level discectomy. However, few studies have addressed the extent of changes in segmental mobility after CDA or their clinical correlations.

METHODS

Data from consecutive patients who underwent 1-level CDA were retrospectively reviewed. Indications for surgery were medically intractable degenerative disc disease and spondylosis. Clinical outcomes, including visual analog scale (VAS)–measured neck and arm pain, Neck Disability Index (NDI), and Japanese Orthopaedic Association (JOA) scores, were analyzed. Radiographic outcomes, including C2–7 Cobb angle, the difference between pre- and postoperative C2–7 Cobb angle (ΔC2–7 Cobb angle), sagittal vertical axis (SVA), the difference between pre- and postoperative SVA (ΔSVA), segmental range of motion (ROM), and the difference between pre- and postoperative ROM (ΔROM), were assessed for their association with clinical outcomes. All patients underwent CT scanning, by which the presence and severity of heterotopic ossification (HO) were determined during the follow-up.

RESULTS

A total of 50 patients (mean age 45.6 ± 9.33 years) underwent a 1-level CDA (Prestige LP disc) and were followed up for a mean duration of 27.7 ± 8.76 months. All clinical outcomes, including VAS, NDI, and JOA scores, improved significantly after surgery. Preoperative and postoperative ROM values were similar (mean 9.5° vs 9.0°, p > 0.05) at each indexed level. The mean changes in segmental mobility (ΔROM) were −0.5° ± 6.13°. Patients with increased segmental mobility after surgery (ΔROM > 0°) had a lower incidence of HO and HO that was less severe (p = 0.048) than those whose ΔROM was < 0°. Segmental mobility (ROM) was significantly lower in patients with higher HO grade (p = 0.012), but it did not affect the clinical outcomes. The preoperative and postoperative C2–7 Cobb angles and SVA remained similar. The postoperative C2–7 Cobb angles, SVA, ΔC2–7 Cobb angles, and ΔSVA were not correlated to clinical outcomes after CDA.

CONCLUSIONS

Segmental mobility (as reflected by the mean ROM) and overall cervical alignment (i.e., mean SVA and C2–7 Cobb angle) had no significant impact on clinical outcomes after 1-level CDA. Patients with increased segmental mobility (ΔROM > 0°) had significantly less HO and similarly improved clinical outcomes than those with decreased segmental mobility (ΔROM < 0°).

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Chih-Chang Chang, Jau-Ching Wu, Peng-Yuan Chang, Mei-Yin Yeh, Yi-Hsuan Kuo, Li-Yu Fay, Tsung-Hsi Tu, Wen-Cheng Huang and Henrich Cheng

There are many kinds of artificial discs available for cervical disc arthroplasty (CDA), with various designs of fixation and articulation mechanisms. Each of these designs has different features and theoretically fits most optimally in selected types of patients. However, there has been insufficient literature to guide individualized selection among these CDA devices. Since CDA aims to restore the joint function rather than arthrodesis, tailor-made size, shape, and mechanical properties should be taken into account for each candidate's target disc. Despite several large-scale prospective randomized control trials that have demonstrated the effectiveness and durability of CDA for up to 8 years, none of them involved more than one kind of artificial disc. In this video the authors present detailed steps and technical aspects of the newly introduced ProDisc-C Vivo (DePuy Synthes Spine), which has the same ball-and-socket design for controlled, predictable motion as the ProDisc-C. The newly derived teeth fixation provides high primary stability and multilevel capability by avoidance of previous keel-related limitations and complications (e.g., split vertebral fracture). Please note that the ProDisc-C Vivo is currently not available on the US market.

The authors present the case of a 53-year-old woman who had symptoms of both radiculopathy and myelopathy caused by a large, calcified disc herniation at C4–5. There was no improvement after 4 months of medical treatment and rehabilitation. A single-level CDA was successfully performed with the ProDisc-C Vivo, and her symptoms were completely ameliorated afterward. The follow-up images demonstrated preservation of motion at the indexed level.

The video can be found here: https://youtu.be/4DSES1xgvQU.