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Sehan Park, Dong-Ho Lee, Saemin Hwang, Soohyun Oh, Do-yon Hwang, Jae Hwan Cho, Chang Ju Hwang, and Choon Sung Lee

OBJECTIVE

Local bone dust has been used previously as a substitute cage filling material for iliac bone grafts during anterior cervical discectomy and fusion (ACDF). However, the impacts of local bone dust on fusion rate and clinical results remain unclear. Extragraft bone bridging (ExGBB) is a reliable CT finding indicating segmental fusion. This study was conducted to compare fusion rates for the use of local bone dust or an iliac auto bone graft during ACDF surgery and to evaluate the effect of implanting bone graft outside the cage.

METHODS

Ninety-three patients who underwent ACDF at a single institution were included. An iliac bone graft was used as the polyetheretherketone (PEEK) cage filling graft material in 43 patients (iliac crest [IC] group). In the IC group, bone graft material was inserted only inside the cage. Local bone dust was used in 50 patients (local bone [LB] group). Bone graft material was inserted both inside and outside the cage in the LB group. Segmental fusion was assessed by 1) interspinous motion (ISM), 2) intragraft bone bridging (InGBB), and 3) ExGBB. Fusion rates, visual analog scale (VAS) scores for neck and arm pain, and Neck Disability Index (NDI) scores were compared between the 2 groups.

RESULTS

The neck and arm pain VAS scores and NDI score improved significantly in both groups. Fusion rates assessed by ISM and InGBB did not differ significantly between the groups. However, the fusion rate in the LB group was significantly higher than that in the IC group when assessed by ExGBB (p = 0.02).

CONCLUSIONS

Using local bone dust as cage filling material resulted in fusion rates similar to those for an iliac bone graft, while avoiding potential complications and pain caused by iliac bone harvesting. A higher rate of extragraft bone bridge formation was achieved by implanting local bone dust outside the cage.

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Hyung Rae Lee, Dong-Ho Lee, Jae Hwan Cho, Eui Seung Hwang, Sang Yun Seok, Sehan Park, and Choon Sung Lee

OBJECTIVE

The objective of this study was to evaluate the feasibility and complications of the over-the-arch (OTA) technique for screw insertion into the C1 lateral mass in patients in whom conventional techniques (i.e., posterior arch [PA] and inferior lateral mass [ILM]) are not feasible due to 1) PA with a very small height (< 3.5 mm), 2) a caudally tilted PA blocking the inferior part of the C1 lateral mass, or 3) loss of height at the ILM (< 3.5 mm).

METHODS

The authors reviewed the medical records of 60 patients who underwent C1 screw fixation with the OTA technique (13 screws) and the PA/ILM technique (107 screws) between 2011 and 2019. Vertebral artery (VA) injuries, screw malposition, and bony union were radiologically assessed. Clinical outcome measures, including Neck Disability Index (NDI), Japanese Orthopaedic Association (JOA) scale score, and occipital neuralgia, were recorded.

RESULTS

Thirteen OTA screws were successfully inserted without any major complications. NDI and JOA scale scores did not show significant differences between the two groups at final follow-up. No VA injuries were recognized during screw insertion. There was no evidence of ischemic damage to the VA or bony erosion in the occiput or atlas. Medial wall violation was observed in 1 screw (7.7%); however, no C0–1, C1–2, or lateral wall violations were observed. No patients developed new-onset neuralgia postoperatively after C1 fixation with the OTA technique.

CONCLUSIONS

The OTA technique was safe and useful for C1 screw fixation in patients in whom conventional techniques could not be employed.

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Sehan Park, Jae Woo Park, Jin Hoon Park, Choon Sung Lee, Dong-Ho Lee, Chang Ju Hwang, Jae Jun Yang, and Jae Hwan Cho

OBJECTIVE

Metastatic epidural spinal cord compression (MESCC) causes neurological deficits that may hinder ambulation. Understanding the prognostic factors associated with increased neurological recovery and regaining ambulatory functions is important for surgical planning in MESCC patients with neurological deficits. The present study was conducted to elucidate prognostic factors of neurological recovery in MESCC patients.

METHODS

A total of 192 patients who had surgery for MESCC due to preoperative neurological deficits were reviewed. A motor recovery rate ≥ 50% and ambulatory function restoration were defined as the primary favorable endpoints. Factors associated with a motor recovery rate ≥ 50%, regaining ambulatory function, and patient survival were analyzed.

RESULTS

About one-half (48.4%) of the patients had a motor recovery rate ≥ 50%, and 24.4% of patients who were not able to walk due to MESCC before the surgery were able to walk after the operation. The factors “involvement of the thoracic spine” (p = 0.015) and “delayed operation” (p = 0.041) were associated with poor neurological recovery. Low preoperative muscle function grade was associated with a low likelihood of regaining ambulatory functions (p = 0.002). Furthermore, performing the operation ≥ 72 hours after the onset of the neurological deficit significantly decreased the likelihood of regaining ambulatory functions (p = 0.020). Postoperative ambulatory function significantly improved patient survival (p = 0.048).

CONCLUSIONS

Delayed operation and the involvement of the thoracic spine were poor prognostic factors for neurological recovery after MESCC surgery. Furthermore, a more severe preoperative neurological deficit was associated with a lesser likelihood of regaining ambulatory functions postoperatively. Earlier detection of motor weaknesses and expeditious surgical interventions are necessary, not only to improve patient functional status and quality of life but also to enhance survival.

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Dong-Ho Lee, Suk-Kyu Lee, Jae Hwan Cho, Chang Ju Hwang, Choon Sung Lee, Jae Jun Yang, Kook Jong Kim, Jae Hong Park, and Sehan Park

OBJECTIVE

Anterior cervical discectomy and fusion (ACDF) provides a limited workspace, and surgeons often need to access the posterior aspect of the vertebral body to achieve sufficient decompression. Oblique resection of the posterior endplate (trumpet-shaped decompression [TSD]) widens the workspace, enabling removal of lesions behind the vertebral body. This study was conducted to evaluate the efficacy and safety of oblique posterior endplate resection for wider decompression.

METHODS

In this retrospective study, 227 patients who underwent ACDF for the treatment of cervical myelopathy or radiculopathy caused by spondylosis or ossification of the posterior longitudinal ligament and were followed up for ≥ 1 year were included. Patient characteristics, fusion rates, subsidence, and patient-reported outcome measures, including the neck pain visual analog scale (VAS) score, arm pain VAS score, and Neck Disability Index (NDI), were assessed. Patients who underwent TSD during ACDF (TSD group) and those who underwent surgery without TSD (non-TSD group) were compared.

RESULTS

Fifty-seven patients (25.1%) were included in the TSD group and 170 patients (74.9%) in the non-TSD group. In the TSD group, 28.2% ± 5.5% of the endplate was resected, and 26.0% ± 6.1% of the region behind the vertebral body could be visualized via the TSD technique. The resection angle was 26.9° ± 5.9°. The fusion rate assessed on the basis of interspinous motion, intragraft bone bridging, and extragraft bone bridging did not significantly differ between the two groups. Furthermore, there were no significant intergroup differences in subsidence. The patient-reported outcome measures at the 1-year follow-up were also not significantly different between the groups.

CONCLUSIONS

TSD widened the workspace during ACDF, and 26% of the region posterior to the vertebral body could be accessed using this technique. The construct stability was not adversely affected by TSD as demonstrated by the similar fusion and subsidence rates among patients who underwent TSD and those who did not. Therefore, TSD can be safely applied during ACDF when compressive lesions extend behind the vertebral body and are not limited to the disc space, enabling adequate decompression without disrupting the construct stability.