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Wen-Cheng Huang, Jau-Ching Wu, Peng-Yuan Chang, Tsung-Hsi Tu, Yu-Shu Yen and Henrich Cheng

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Chao-Hung Kuo, Peng-Yuan Chang, Jau-Ching Wu, Wen-Cheng Huang, Tsung-Hsi Tu and Henrich Cheng

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

Object

Cervical arthroplasty has been accepted as a viable option for surgical management of cervical spondylosis or degenerative disc disease (DDD). The best candidates for cervical arthroplasty are young patients who have radiculopathy caused by herniated disc with competent facet joints. However, it remains uncertain whether arthroplasty is equally effective for patients who have cervical myelopathy caused by DDD. The aim of this study was to compare the outcomes of arthroplasty for patients with cervical spondylotic myelopathy (CSM) and patients with radiculopathy without CSM.

Methods

A total of 151 consecutive cases involving patients with CSM or radiculopathy caused by DDD and who underwent one- or two-level cervical arthroplasty were included in this study. Clinical outcome evaluations and radiographic studies were reviewed. Clinical outcome measurements included the Visual Analog Scale (VAS) of neck and arm pain, Japanese Orthopaedic Association (JOA) scores, and the Neck Disability Index (NDI) in every patient. For patients with CSM, Nurick scores were recorded for evaluation of cervical myelopathy. Radiographic studies included lateral dynamic radiographs and CT for detection of the formation of heterotopic ossification .

Results

Of the 151 consecutive patients with cervical DDD, 125 (82.8%; 72 patients in the myelopathy group and 53 in the radiculopathy group) had at least 24 months of clinical and radiographic follow-up. The mean duration of follow-up in these patients was 36.4 months (range 24–56 months). There was no difference in sex distribution between the 2 groups. However, the mean age of the patients in the myelopathy group was approximately 6 years greater than that of the radiculopathy group (53.1 vs 47.2 years, p < 0.001). The mean operation time, mean estimated blood loss, and the percentage of patients prescribed perioperative analgesic agents were similar in both groups (p = 0.754, 0.652, and 0.113, respectively). There were significant improvements in VAS neck and arm pain, JOA scores, and NDI in both groups. Nurick scores in the myelopathy group also improved significantly after surgery. In radiographic evaluations, 92.5% of patients in the radiculopathy group and 95.8% of those in the radiculopathy group retained spinal motion (no significant difference). Evaluation of CT scans showed heterotopic ossification in 34 patients (47.2%) in the myelopathy group and 25 patients (47.1%) in the radiculopathy group (p = 0.995). At a mean of over 3 years postoperatively, no secondary surgery was reported in either group.

Conclusions

The severity of myelopathy improves after cervical arthroplasty in patients with CSM caused by DDD. At 3-year follow-up, the clinical and radiographic outcomes of cervical arthroplasty in DDD patients with CSM are similar to those patients who have only cervical radiculopathy. Therefore, cervical arthroplasty is a viable option for patients with CSM caused by DDD who require anterior surgery. However, comparison with the standard surgical treatment of anterior cervical discectomy and fusion is necessary to corroborate the outcomes of arthroplasty for CSM.

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

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Yu-Shu Yen, Peng-Yuan Chang, Wen-Cheng Huang, Jau-Ching Wu, Muh-Lii Liang, Tsung-Hsi Tu and Henrich Cheng

Object

The goal of the study was to report a series of consecutive patients who underwent endoscopic transnasal odontoidectomy (ETO) without resection of nasal turbinates. The techniques for this minimally invasive approach are described in detail.

Methods

The authors conducted a retrospective review of consecutive patients who underwent ETO for basilar invagination. All the patients had myelopathy caused by compression at the cervicomedullary junction, which required surgical decompression. Preoperative and postoperative data, including those from radiographic and clinical evaluations, were compared. Morbidity and mortality rates for the procedure are also reported in detail.

Results

Thirteen patients (6 men and 7 women) with a mean age of 52.7 years (range 24–72 years) were enrolled. The basilar invagination etiologies were rheumatoid arthritis (n = 5), trauma (n = 4), os odontoideum (n = 2), ankylosing spondylitis (n = 1), and postinfectious deformity (n = 1). The average follow-up duration was 51.2 months (range 0.3–105 months). One patient died 10 days after the operation as a result of meningitis caused by CSF leakage. Among the other 12 patients, the average postoperative Nurick grade (3.2) was significantly improved over that before the operation (4.1, p = 0.004). The mean (± SD) duration of postoperative intubation was 1.5 ± 2.1 days, and there was no need for perioperative tracheostomy or nasogastric tube feeding. There also was no postoperative velopharyngeal insufficiency. There were 6 (46%) intraoperative and 2 (15%) postoperative CSF leaks in the 13 patients in this series.

Conclusions

ETO is a viable and effective option for decompression at the ventral cervicomedullary junction. This approach is minimally invasive and causes little velopharyngeal insufficiency. The pitfall of this approach is the difficulty in repairing dural defects and subsequent CSF leakage.

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

OBJECT

Heterotopic ossification (HO) after cervical arthroplasty is not uncommon and may cause immobility of the disc. To prevent HO formation, study protocols of clinical trials for cervical arthroplasty undertaken by the US FDA included perioperative use of nonsteroidal antiinflammatory drugs (NSAIDs). However, there are few data supporting the use of NSAIDs to prevent HO after cervical arthroplasty. Therefore, this study aimed to evaluate the efficacy of NSAIDs in HO formation and clinical outcomes.

METHODS

Consecutive patients who underwent 1- or 2-level cervical arthroplasty with a minimum follow-up of 24 months were retrospectively reviewed. All patients were grouped into 1 of 2 groups, an NSAID group (those patients who had used NSAIDs postoperatively) and a non-NSAID group (those patients who had not used NSAIDs postoperatively). The formation of HO was detected and classified using CT in every patient. The incidence of HO formation, disc mobility, and clinical outcomes, including visual analog scale (VAS) scores of neck and arm pain, neck disability index (NDI) scores, and complications were compared between the two groups. Furthermore, a subgroup analysis of the patients in the NSAID group, comparing the selective cyclooxygenase (COX)-2 to nonselective COX-2 NSAID users, was also conducted for each of the above-mentioned parameters.

RESULTS

A total of 75 patients (mean age [± SD] 46.71 ± 9.94 years) with 107 operated levels were analyzed. The mean follow-up duration was 38.71 ± 9.55 months. There were no significant differences in age, sex, and levels of arthroplasty between the NSAID and non-NSAID groups. There was a nonsignificantly lower rate of HO formation in the NSAID group than the non-NSAID group (47.2% vs. 68.2%, respectively; p = 0.129). During follow-up, most of the arthroplasty levels remained mobile, with similar rates of immobile discs in the NSAID and non-NSAID groups (13.2% and 22.7%, respectively; p = 0.318). Furthermore, there was a nonsignificantly lower rate of HO formation in the selective COX-2 group than the nonselective COX-2 group (30.8% vs 52.5%, respectively; p = 0.213). The clinical outcomes, including VAS neck, VAS arm, and NDI scores at 24 months postoperatively, were all similar in the NSAID and non-NSAID groups, as well as the selective and nonselective COX-2 groups (all p > 0.05).

CONCLUSIONS

In this study there was a trend toward less HO formation and fewer immobile discs in patients who used postoperative NSAIDs after cervical arthroplasty than those who did not, but this trend did not reach statistical significance. Patients who used selective COX-2 NSAIDs had nonsignificantly less HO than those who used nonselective COX-2 NSAIDs. The clinical outcomes were not affected by the use of NSAIDs or the kinds of NSAIDs used (selective vs nonselective COX-2). However, the study was limited by the number of patients included, and the efficacy of NSAIDs in the prevention of HO after cervical arthroplasty may need further investigation to confirm these results.

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

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

OBJECTIVE

In the past decade, dynamic stabilization has been an emerging option of surgical treatment for lumbar spondylosis. However, the application of this dynamic construct for mild spondylolisthesis and its clinical outcomes remain uncertain. This study aimed to compare the outcomes of Dynesys dynamic stabilization (DDS) with minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for the management of single-level spondylolisthesis at L4–5.

METHODS

This study retrospectively reviewed 91 consecutive patients with Meyerding Grade I spondylolisthesis at L4–5 who were managed with surgery. Patients were divided into 2 groups: DDS and MI-TLIF. The DDS group was composed of patients who underwent standard laminectomy and the DDS system. The MI-TLIF group was composed of patients who underwent MI-TLIF. Clinical outcomes were evaluated by visual analog scale for back and leg pain, Oswestry Disability Index, and Japanese Orthopaedic Association scores at each time point of evaluation. Evaluations included radiographs and CT scans for every patient for 2 years after surgery.

RESULTS

A total of 86 patients with L4–5 spondylolisthesis completed the follow-up of more than 2 years and were included in the analysis (follow-up rate of 94.5%). There were 64 patients in the DDS group and 22 patients in the MI-TLIF group, and the overall mean follow-up was 32.7 months. Between the 2 groups, there were no differences in demographic data (e.g., age, sex, and body mass index) or preoperative clinical evaluations (e.g., visual analog scale back and leg pain, Oswestry Disability Index, and Japanese Orthopaedic Association scores). The mean estimated blood loss of the MI-TLIF group was lower, whereas the operation time was longer compared with the DDS group (both p < 0.001). For both groups, clinical outcomes were significantly improved at 6, 12, 18, and 24 months after surgery compared with preoperative clinical status. Moreover, there were no differences between the 2 groups in clinical outcomes at each evaluation time point. Radiological evaluations were also similar and the complication rates were equally low in both groups.

CONCLUSIONS

At 32.7 months postoperation, the clinical and radiological outcomes of DDS were similar to those of MI-TLIF for Grade I degenerative spondylolisthesis at L4–5. DDS might be an alternative to standard arthrodesis in mild lumbar spondylolisthesis. However, unlike fusion, dynamic implants have issues of wearing and loosening in the long term. Thus, the comparable results between the 2 groups in this study require longer follow-up to corroborate.