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Che-Han Hsu, Yi-Hsuan Kuo, Chao-Hung Kuo, Chin-Chu Ko, Jau-Ching Wu, and Wen-Cheng Huang

BACKGROUND

Heterotopic ossification (HO) is a well-documented complication of cervical disc arthroplasty (CDA), although it rarely causes adverse clinical effects. Despite high-grade HO possibly limiting segmental mobility, it is reportedly seldom associated with symptoms.

OBSERVATIONS

The authors report a case of a 46-year-old male patient who underwent hybrid CDA and anterior cervical discectomy and fusion for 3-level cervical disc herniation that caused myeloradiculopathy. The surgery was successful; the patient experienced nearly complete recovery postoperatively. The follow-up images, including computed tomography and magnetic resonance imaging scans, showed satisfactory decompression at the indexed levels without residual osteophytes or ossification of the posterior longitudinal ligament. However, 10 years later, the patient presented with symptomatic compressive myelopathy caused by severe HO that prompted a secondary surgery.

LESSONS

Although it is generally reported in the literature that HO is clinically innocuous, in this patient, it gradually and progressively developed and caused myelopathy, requiring a secondary surgery. Symptomatic HO can be expected over time, and patients with a high risk of HO deserve long-term follow-up after CDA. Further investigations are warranted to corroborate these risk factors, including multilevel calcified disc herniation, severe spondylosis, and suboptimal placement of the device during primary CDA surgery.

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

OBJECTIVE

The published clinical trials of cervical disc arthroplasty (CDA) have unanimously demonstrated the success of preservation of motion (average 7°–9°) at the index level for up to 10 years postoperatively. The inclusion criteria in these trials usually required patients to have evident mobility at the level to be treated (≥ 2° on lateral flexion-extension radiographs) prior to the surgery. Although the mean range of motion (ROM) remained similar after CDA, it was unclear in these trials if patients with less preoperative ROM would have different outcomes than patients with more ROM.

METHODS

A series of consecutive patients who underwent CDA at the level of C5–6 were followed up and retrospectively reviewed. The indications for surgery were medically refractory cervical radiculopathy, myelopathy, or both, caused by cervical disc herniation or spondylosis. All patients were assigned to 1 of 2 groups: a less-mobile group, which consisted of those patients who had an ROM of ≤ 5° at C5–6 preoperatively, or a more-mobile group, which consisted of patients whose ROM at C5–6 was > 5° preoperatively. Clinical outcomes, including visual analog scale, Neck Disability Index, and Japanese Orthopaedic Association Scale scores, were evaluated at each time point. Radiological outcomes were also assessed.

RESULTS

A total of 60 patients who had follow-up for more than 2 years were analyzed. There were 27 patients in the less-mobile group (mean preoperative ROM 3.0°) and 33 in the more-mobile group (mean ROM 11.7°). The 2 groups were similar in demographics, including age, sex, diabetes, and cigarette smoking. Both groups had significant improvements in clinical outcomes, with no significant differences between the 2 groups. However, the radiological evaluations demonstrated remarkable differences. The less-mobile group had a greater increase in ΔROM than the more-mobile group (ΔROM 5.5° vs 0.1°, p = 0.001), though the less-mobile group still had less segmental mobility (ROM 8.5° vs 11.7°, p = 0.04). The rates of complications were similar in both groups.

CONCLUSIONS

Preoperative segmental mobility did not alter the clinical outcomes of CDA. The preoperatively less-mobile (ROM ≤ 5°) discs had similar clinical improvements and greater increase of segmental mobility (ΔROM), but remained less mobile, than the preoperatively more-mobile (ROM > 5°) discs at 2 years postoperatively.

Restricted access

Chao-Jui Chang, Yuan-Fu Liu, Yu-Meng Hsiao, Yi-Hung Huang, Keng-Chang Liu, Ruey-Mo Lin, and Cheng-Li Lin

OBJECTIVE

Anterior cervical discectomy and fusion (ACDF) has long been regarded as a gold standard in the treatment of cervical myelopathy. Subsequently, cervical artificial disc replacement (c-ADR) was developed and provides the advantage of motion preservation at the level of the intervertebral disc surgical site, which may also reduce stress at adjacent levels. The goal of this study was to compare clinical and functional outcomes in patients undergoing ACDF with those in patients undergoing c-ADR for cervical spondylotic myelopathy (CSM).

METHODS

A systematic literature review and meta-analysis were performed using the Embase, PubMed, and Cochrane Central Register of Controlled Trials databases from database inception to November 21, 2021. The authors compared Neck Disability Index (NDI), SF-36, and Japanese Orthopaedic Association (JOA) scores; complication rates; and reoperation rates for these two surgical procedures in CSM patients. The Mantel-Haenszel method and variance-weighted means were used to analyze outcomes after identifying articles that met study inclusion criteria.

RESULTS

More surgical time was consumed in the c-ADR surgery (p = 0.04). Shorter hospital stays were noted in patients who had undergone c-ADR (p = 0.04). Patients who had undergone c-ADR tended to have better NDI scores (p = 0.02) and SF-36 scores (p = 0.001). Comparable outcomes in terms of JOA scores (p = 0.24) and neurological success rate (p = 0.12) were noted after the surgery. There was no significant between-group difference in the overall complication rates (c-ADR: 18% vs ACDF: 25%, p = 0.17). However, patients in the ACDF group had a higher reoperation rate than patients in the c-ADR group (4.6% vs 1.5%, p = 0.02).

CONCLUSIONS

At the midterm follow-up after treatment of CSM, better functional outcomes as reflected by NDI and SF-36 scores were noted in the c-ADR group than those in the ACDF group. c-ADR had the advantage of retaining range of motion at the level of the intervertebral disc surgical site without causing more complications. A large sample size with long-term follow-up studies may be required to confirm these findings in the future.

Free access

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.