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Takeshi Oichi, Yasushi Oshima, Hiroyuki Oka, Yuki Taniguchi, Hirotaka Chikuda, Yoshitaka Matsubayashi, Katsushi Takeshita, and Sakae Tanaka

OBJECTIVE

Several investigators have reported the occurrence of interlaminar bony fusion after cervical laminoplasty, which is reportedly associated with reduced postoperative cervical range of motion (ROM). However, to the authors’ knowledge, no previous study has investigated the characteristics of patients who were likely to develop interlaminar bony fusion after cervical laminoplasty. Therefore, the objective of this study was to investigate the risk factors for interlaminar bony fusion in patients with cervical spondylotic myelopathy (CSM) following cervical laminoplasty and to investigate the effect of interlaminar bony fusion on surgical outcomes.

METHODS

The authors retrospectively reviewed data from 92 patients with CSM (63 men and 29 women) after cervical laminoplasty. The presence of interlaminar bony fusion was evaluated by functional radiographs 2 years after surgery. The patients were divided into 2 groups according to the presence of postoperative interlaminar bony fusion: a fusion group (at least 1 new postoperative interlaminar bony fusion) and a nonfusion group (no new interlaminar bony fusion). Potential risk factors for postoperative interlaminar bony fusion were assessed, including diabetes mellitus, smoking status, whether the C-2 lamina was included in the surgical treatment, C2–7 Cobb angle in each cervical position, preoperative cervical ROM, and T-1 slope. The differences in each variable were compared between the fusion and nonfusion groups. Thereafter, multivariate logistic regression analysis was performed to identify the risk factors for postoperative interlaminar bony fusion. For surgical outcomes, the recovery rate based on Japanese Orthopaedic Association scores and the reduction rate of cervical ROM were evaluated 2 years after surgery.

RESULTS

Interlaminar bony fusion was observed in 60 cases, 52 of which were observed at the C2–3 level. Patients in the fusion group were significantly older, had a significantly larger C2–7 angle in flexion, and had a significantly lower preoperative cervical ROM than those in the nonfusion group. A high T-1 slope was significantly more frequent in the fusion group. Multivariate analysis revealed that the significant risk factors for postoperative interlaminar bony fusion were high T-1 slope (odds ratio 4.81; p = 0.0015) and older age (odds ratio 1.05; p = 0.025). The Japanese Orthopaedic Association recovery rate in patients with interlaminar bony fusion did not differ significantly from those without bony fusion (45% vs 48%; p = 0.73). However, patients with bony fusion showed significantly reduced postoperative cervical ROM compared with those without bony fusion (50% vs 25%; p < 0.001).

CONCLUSIONS

High T-1 slope and older age were significant risk factors for developing interlaminar bony fusion after cervical laminoplasty in patients with CSM. Interlaminar bony fusion was associated with reduced postoperative cervical ROM, but it did not affect neurological outcomes.

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Junichi Ohya, Yasushi Oshima, Hirotaka Chikuda, Takeshi Oichi, Hiroki Matsui, Kiyohide Fushimi, Sakae Tanaka, and Hideo Yasunaga

OBJECTIVE

Although minimally invasive spinal surgery has recently gained popularity, few nationwide studies have compared the adverse events that occur during endoscopic versus open spinal surgery. The purpose of this study was to compare perioperative complications associated with microendoscopic discectomy (MED) and open discectomy for patients with lumbar disc herniation.

METHODS

The authors retrospectively extracted from the Diagnosis Procedure Combination database, a national inpatient database in Japan, data for patients admitted between July 2010 and March 2013. Patients who underwent lumbar discectomy without fusion surgery were included in the analysis, and those with an urgent admission were excluded. The authors examined patient age, sex, Charlson Comorbidity Index, body mass index, smoking status, blood transfusion, duration of anesthesia, type of hospital, and hospital volume (number of patients undergoing discectomy at each hospital). One-to-one propensity score matching between the MED and open discectomy groups was performed to compare the proportions of in-hospital deaths, surgical site infections (SSIs), and major complications, including stroke, acute coronary events, pulmonary embolism, respiratory complications, urinary tract infection, and sepsis. The authors also compared the hospital length of stay between the 2 groups.

RESULTS

A total of 26,612 patients were identified in the database. The mean age was 49.6 years (SD 17.7 years). Among all patients, 17,406 (65.4%) were male and 6422 (24.1%) underwent MED. A propensity score–matched analysis with 6040 pairs of patients showed significant decreases in the occurrence of major complications (0.8% vs 1.3%, p = 0.01) and SSI (0.1% vs 0.2%, p = 0.02) in patients treated with MED compared with those who underwent open discectomy. Overall, MED was associated with significantly lower risks of major complications (OR 0.62, 95% CI 0.43–0.89, p = 0.01) and SSI (OR 0.29, 95% CI 0.09–0.87, p = 0.03) than open discectomy. There was a significant difference in length of hospital stay (11 vs 15 days, p < 0.001) between the groups. There was no significant difference in in-hospital mortality between MED and open discectomy.

CONCLUSIONS

The microendoscopic technique was associated with lower risks for SSI and major complications following discectomy in patients with lumbar disc herniation.

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Shuhei Murase, Yasushi Oshima, Yujiro Takeshita, Kota Miyoshi, Kazuhito Soma, Naohiro Kawamura, Junichi Kunogi, Takashi Yamazaki, Dai Ariyoshi, Shigeo Sano, Hirohiko Inanami, Katsushi Takeshita, and Sakae Tanaka

OBJECTIVE

Interbody fusion cages are widely used to achieve initial fixation and secure spinal fusion; however, there are certain technique-related complications. Although anterior cage dislodgement can cause major vascular injury, the incidence is extremely rare. Here, the authors performed a review of anterior cage dislodgement following posterior lumbar interbody fusion (PLIF) surgery.

METHODS

The authors retrospectively reviewed the cases of 4625 patients who had undergone PLIF at 6 institutions between December 2007 and March 2015. They investigated the incidence and causes of surgery-related anterior cage dislodgement, salvage mechanisms, and postoperative courses.

RESULTS

Anterior cage dislodgement occurred in 12 cases (0.26%), all of which were caused by technical errors. In 9 cases, excessive cage impaction resulted in dislodgement. In 2 cases, when the cage on the ipsilateral side was inserted, it interacted and pushed out the other cage on the opposite side. In 1 case, the cage was positioned in an extreme lateral and anterior part of the intervertebral disc space, and it postoperatively dislodged. In 3 cases, the cage was removed in the same operative field. In the remaining 9 cases, CT angiography was performed postoperatively to assess the relationship between the dislodged cage and large vessels. Dislodged cages were conservatively observed in 2 cases. In 7 cases, the cage was removed because it was touching or compressing large vessels, and an additional anterior approach was selected. In 2 patients, there was significant bleeding from an injured inferior vena cava. There were no further complications or sequelae associated with the dislodged cages during the follow-up period.

CONCLUSIONS

Although rare, iatrogenic anterior cage dislodgement following a PLIF can occur. The authors found that technical errors made by experienced spine surgeons were the main causes of this complication. To prevent dislodgement, the surgeon should be cautious when inserting the cage, avoiding excessive cage impaction and ensuring cage control. Once dislodgement occurs, the surgeons must immediately address this difficult complication. First, the possibility of a large vessel injury should be considered. If the patient’s vital signs are stable, the surgeon should continue with the surgery without cage removal and perform CT angiography postoperatively to assess the cage location. Blind maneuvers should be avoided when the surgical site cannot be clearly viewed. When the cage compresses or touches the aortic artery or vena cava, it is better to remove the cage to avoid late-onset injury to major vessels. When the cage does not compress or touch vessels, its removal is controversial. The risk factors associated with performing another surgery should be evaluated on a case-by-case basis.

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Takeshi Oichi, Hirotaka Chikuda, Teppei Morikawa, Harushi Mori, Daisuke Kitamura, Junya Higuchi, Yuki Taniguchi, Yoshitaka Matsubayashi, Yasushi Oshima, and Sakae Tanaka

Dumbbell-shaped tumors consisting of 2 different tumors are extremely rare. Herein, the authors present a case of concurrent spinal schwannoma and meningioma mimicking a single cervical dumbbell-shaped tumor. A 64-year-old man presented with a 5-year history of gradually exacerbating left occipital pain without clinical evidence of neurofibromatosis. Magnetic resonance imaging showed an extradural tumor along the left C-2 nerve root with a small intradural component. The tumor was approached via a C-1 hemilaminectomy. The intradural tumor was resected together with the extradural tumor after opening the dura mater. The intradural tumor was attached to the dura mater around the exit point of the C-2 nerve root. Intraoperative biopsy revealed that the extradural tumor was a schwannoma and that the intradural tumor was a meningioma. The dura mater adjacent to the tumor was then coagulated and resected. Postoperative pathological examination confirmed the same diagnoses with no evidence of continuity between the intra- and extradural components. The patient’s postoperative clinical course was uneventful. Clinicians should be aware that cervical dumbbell-shaped tumors can consist of 2 different tumors.

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Toru Doi, Ryuji Sakamoto, Chiaki Horii, Naoki Okamoto, Koji Nakajima, Shima Hirai, Fumihiko Oguchi, So Kato, Yuki Taniguchi, Yoshitaka Matsubayashi, Naoto Hayashi, Sakae Tanaka, and Yasushi Oshima

OBJECTIVE

The incidence and risk factors for the progression of ossification of the posterior longitudinal ligament (OPLL) have been previously reported in surgically and nonsurgically treated symptomatic patients. However, the correlates of OPLL progression in asymptomatic subjects with OPLL are not well characterized. This study aimed to clarify the incidence and risk factors for OPLL progression in asymptomatic subjects based on whole-body CT.

METHODS

The authors retrospectively reviewed 2585 healthy subjects who underwent whole-body CT at a single health center from September 2007 to December 2011. This study included asymptomatic subjects with OPLL who underwent CT scans twice with an interval of at least 5 years. Progression of OPLL was assessed based on initial and final CT scan. Subjects were divided into two groups: nonprogression (OPLL-NP) and progression (OPLL-P) groups. Clinical characteristics, bone mineral density status, OPLL types, and OPLL involvement of multiple vertebral levels between the two groups were compared. Risk factors for progression of OPLL were identified by logistic regression analysis after propensity score adjustment.

RESULTS

Of the 109 subjects with OPLL (91 men and 18 women), 20 (18.3%) exhibited OPLL progression (OPLL-P group). Subjects in the OPLL-P group were significantly younger (p = 0.031), had higher prevalence of multilevel OPLL involvement (p = 0.041) and continuous type of OPLL (p = 0.015), and had higher uric acid (UA) levels (p = 0.004) at the time of initial CT examination compared to the OPLL-NP group. Younger age (adjusted odds ratio [aOR] 0.95, 95% CI 0.90–0.99), OPLL involvement of multiple vertebral levels (aOR 2.88, 95% CI 1.06–7.83), continuous type of OPLL (aOR 4.21, 95% CI 1.35–13.10), and higher UA levels (aOR 2.09, 95% CI 1.24–3.53) were significant risk factors for OPLL progression.

CONCLUSIONS

Younger age, OPLL involvement of multiple vertebral levels, continuous type of OPLL, and higher UA levels are significant risk factors for OPLL progression in asymptomatic subjects.

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Toru Doi, Hideki Nakamoto, Koji Nakajima, Shima Hirai, Yusuke Sato, So Kato, Yuki Taniguchi, Yoshitaka Matsubayashi, Ko Matsudaira, Katsushi Takeshita, Sakae Tanaka, and Yasushi Oshima

OBJECTIVE

Preoperative mood disorders such as depression and anxiety are known to be associated with poor health-related quality of life (HRQOL) outcomes after lumbar spine surgery. However, the effects of preoperative depression and anxiety on postoperative HRQOL outcomes and patient satisfaction in cervical compressive myelopathy are yet to be clarified. This study aimed to investigate the effect of depression and anxiety on HRQOL outcomes and patient satisfaction following surgery for cervical compressive myelopathy.

METHODS

The authors reviewed the cases of all consecutive patients with cervical compressive myelopathy who had undergone surgical treatment in the period between January 2012 and March 2017 at their institution. Using the Hospital Anxiety and Depression Scale (HADS), the authors classified patients as depressed (HADS-D+) or not depressed (HADS-D−) and anxious (HADS-A+) or not anxious (HADS-A−). Patient HRQOL was evaluated preoperatively and at the end of at least 1 year after surgery using the physical and mental component summaries of the SF-12 Health Survey, EQ-5D (EuroQol health survey of five dimensions), Neck Disability Index, and Japanese Orthopaedic Association scale. Patient satisfaction was evaluated on the basis of a seven-item questionnaire and divided into two categories: satisfied and dissatisfied. Preoperative HRQOL statuses, postoperative improvements in HRQOL outcomes, and patient satisfaction were compared between the groups.

RESULTS

Among the 121 patients eligible for inclusion in the study, there were 69 patients (57.0%) without depression (HADS-D−) and 52 (43.0%) with depression (HADS-D+) and 82 patients (67.8%) without anxiety (HADS-A−) and 39 (32.2%) with anxiety (HADS-A+). All patients who completed both the preoperative and postoperative questionnaires had significant postoperative improvements in all HRQOL outcomes. The HADS-D+ and HADS-A+ patients had poorer preoperative HRQOL statuses than the HADS-D− and HADS-A− patients, respectively. However, statistically significant improvements in all HRQOL outcomes were observed in both HADS-D+ and HADS-A+ patients. Patient satisfaction was comparable between the HADS-D or HADS-A groups.

CONCLUSIONS

Cervical compressive myelopathy patients with preoperative depression or anxiety according to the HADS tool had worse preoperative HRQOL statuses. However, patients with cervical compressive myelopathy showed significant improvements in HRQOL outcomes and had sufficient levels of satisfaction after surgery regardless of the presence of preoperative depression or anxiety.

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Junya Miyahara, Yuichi Yoshida, Mitsuhiro Nishizawa, Hiroyuki Nakarai, Yudai Kumanomido, Keiichiro Tozawa, Yukimasa Yamato, Masaaki Iizuka, Jim Yu, Katsuyuki Sasaki, Masahito Oshina, So Kato, Toru Doi, Yuki Taniguchi, Yoshitaka Matsubayashi, Akiro Higashikawa, Yujiro Takeshita, Takashi Ono, Nobuhiro Hara, Seiichi Azuma, Naohiro Kawamura, Sakae Tanaka, and Yasushi Oshima

OBJECTIVE

The aim of this study was to compare perioperative complications and postoperative outcomes between patients with lumbar recurrent stenosis without lumbar instability and radiculopathy who underwent decompression surgery and those who underwent decompression with fusion surgery.

METHODS

For this retrospective study, the authors identified 2606 consecutive patients who underwent posterior surgery for lumbar spinal canal stenosis at eight affiliated hospitals between April 2017 and June 2019. Among these patients, those with a history of prior decompression surgery and central canal restenosis with cauda equina syndrome were included in the study. Those patients with instability or radiculopathy were excluded. The patients were divided between the decompression group and decompression with fusion group. The demographic characteristics, numerical rating scale score for low-back pain, incidence rates of lower-extremity pain and lower-extremity numbness, Oswestry Disability Index score, 3-level EQ-5D score, and patient satisfaction rate were compared between the two groups using the Fisher’s exact probability test for nominal variables and the Student t-test for continuous variables, with p < 0.05 as the level of statistical significance.

RESULTS

Forty-six patients met the inclusion criteria (35 males and 11 females; 19 patients underwent decompression and 27 decompression and fusion; mean ± SD age 72.5 ± 8.8 years; mean ± SD follow-up 18.8 ± 6.0 months). Demographic data and perioperative complication rates were similar. The percentages of patients who achieved the minimal clinically important differences for patient-reported outcomes or satisfaction rate at 1 year were similar.

CONCLUSIONS

Among patients with central canal stenosis who underwent revision, the short-term outcomes of the patients who underwent decompression were comparable to those of the patients who underwent decompression and fusion. Decompression surgery may be effective for patients without instability or radiculopathy.

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Takaki Inoue, Satoshi Maki, Toshitaka Yoshii, Takeo Furuya, Satoru Egawa, Kenichiro Sakai, Kazuo Kusano, Yukihiro Nakagawa, Takashi Hirai, Kanichiro Wada, Keiichi Katsumi, Kengo Fujii, Atsushi Kimura, Narihito Nagoshi, Tsukasa Kanchiku, Yukitaka Nagamoto, Yasushi Oshima, Kei Ando, Masahiko Takahata, Kanji Mori, Hideaki Nakajima, Kazuma Murata, Shunji Matsunaga, Takashi Kaito, Kei Yamada, Sho Kobayashi, Satoshi Kato, Tetsuro Ohba, Satoshi Inami, Shunsuke Fujibayashi, Hiroyuki Katoh, Haruo Kanno, Shiro Imagama, Masao Koda, Yoshiharu Kawaguchi, Katsushi Takeshita, Morio Matsumoto, Seiji Ohtori, Masashi Yamazaki, Atsushi Okawa, and

OBJECTIVE

It is unclear whether anterior cervical decompression and fusion (ADF) or laminoplasty (LMP) results in better outcomes for patients with K-line–positive (+) cervical ossification of the posterior longitudinal ligament (OPLL). The purpose of the study is to compare surgical outcomes and complications of ADF versus LMP in patients with K-line (+) OPLL.

METHODS

The study included 478 patients enrolled in the Japanese Multicenter Research Organization for Ossification of the Spinal Ligament and who underwent surgical treatment for cervical OPLL. The patients who underwent anterior-posterior combined surgery or posterior decompression with instrumented fusion were excluded. The patients with a follow-up period of fewer than 2 years were also excluded, leaving 198 patients with K-line (+) OPLL. Propensity score matching was performed on 198 patients with K-line (+) OPLL who underwent ADF (44 patients) or LMP (154 patients), resulting in 39 pairs of patients based on the following predictors for surgical outcomes: age, preoperative Japanese Orthopaedic Association (JOA) score, C2–7 angle, and the occupying ratio of OPLL. Clinical outcomes were assessed 1 and 2 years after surgery using the recovery rate of the JOA score. Complications and reoperation rates were also investigated.

RESULTS

The mean recovery rate of the JOA score 1 year after surgery was 55.3% for patients who underwent ADF and 42.3% (p = 0.06) for patients who underwent LMP. Two years after surgery, the recovery rate was 53.4% for those who underwent ADF and 38.7% for LMP (p = 0.07). Although both surgical procedures yielded good results, the mean recovery rate of JOA scores tended to be higher in the ADF group. The incidence of surgical complications, however, was higher following ADF (33%) than LMP (15%; p = 0.06). The reoperation rate was also higher in the ADF group (15%) than in the LMP group (0%; p = 0.01).

CONCLUSIONS

Clinical outcomes were good for both ADF and LMP, indicating that ADF and LMP are appropriate procedures for patients with K-line (+) OPLL. Clinical outcomes of ADF 1 and 2 years after surgery tended to be better than LMP, but the analysis did not detect any significant difference in clinical outcomes between the groups. Conversely, patients who underwent ADF had a higher incidence of surgery-related complications. When considering indications for ADF or LMP, benefits and risks of the surgical procedures should be carefully weighed.