Detailed clinical information of 13 adult patients with acute atlantal fractures underwent nonoperative treatment was retrospectively studied. “Rule of Spence” was found inaccurate in predicting either integrity of transverse atlantal ligament (TAL) or atlantoaxial stability, whereas Dickman's classification of TAL injury was more superior to “rule of Spence” on both prediction. Study Design. A retrospective study. Objective. To evaluate the prediction accuracy of “Rule of Spence” and Dickman's classification of the transverse atlantal ligament (TAL) injury on clinical outcomes (mainly focused on atlantoaxial stability) of atlas fractures treated nonoperatively. Summary of Background Data. TAL is regarded as primary stabilizer of the atlantoaxial complex. Atlas fractures are categorized as unstable and stable according to TAL injury or not. “Rule of Spence” and Dickman's classification have been widely used to evaluate the integrity of TAL indirectly or directly. However, there is controversy about how to interpret and apply these image measures appropriately in treatment decision making, and comparing the two measures in same cohort has been lack. Methods. From January 2013 to December 2015, 13 adult patients with atlas fractures, treated nonoperatively at acute posttraumatic phase and followed up for at least 2 years, were enrolled in the study. Lateral mass offset (LMO) and TAL injury were measured by radiography. Atlantoaxial stability, pain in occipital region, limitation of cervical motion, neurological dysfunction, and quality of daily life were evaluated as clinical outcomes. Results. LMO less than 6.9 mm was inaccurate either to exclud TAL injury (4/8, 50% failed) or to predict clinical outcomes (2/8, 25% failed), whereas LMO greater than 6.9 mm was accurate to determine TAL injury (5/5, 100% succeeded) but not to predict atlantoaxial stability (4/5, 80% failed). Two cases with Dickman's classification type I injury (100%) failed to restore C1-2 stability and six of seven type II (85.7%) succeeded. Three patients were indicated for fusion surgery due to instability, and one due to traumatic arthritis. Overall clinical outcomes were satisfactory as pain and quality of life were considered. Conclusion. Dickman‘s classification of TAL injury is of higher superiority to “Rule of Spence” in term of the accuracy of predicting atlantoaxial stability of nonoperatively treated atlas fractures. Level of Evidence: 4
To detect painful vertebral fractures (VFs) in back pain populations at risk of osteoporosis, we designed a physical examination test (the Back Pain‐Inducing Test [BPIT]) that included three movements: lying supine, rolling over, and sitting up. If back pain is induced during any of these movements, the result is defined as positive, thereby establishing a presumptive diagnosis of painful VFs. Pain severity is quantified using a self‐reported numerical rating scale (NRS). The presence or absence of painful VFs is verified by whole‐spine magnetic resonance imaging (MRI), the gold standard for final diagnosis. According to the standards for reporting diagnostic accuracy, a real‐world, prospective, and observational study was performed on 510 back pain patients (enrolled from a single institute) at risk of osteoporosis. The sensitivity, specificity, and accuracy of the BPIT for identifying painful VFs were 99.1% (95% CI, 97.5% to 99.8%), 67.9% (95% CI, 60.4% to 74.5%), and 89.0%, respectively. The positive and negative predictive values were 86.6% (95% CI, 82.9% to 89.6%) and 97.4% (95% CI, 92.6% to 99.3%), respectively. Cutoff NRS scores for lying supine, rolling over, and sitting up were 3, 0, and 2, respectively. The corresponding area under the receiver operating characteristic curves (AUROCs) of each movement was 0.898 (95% CI, 0.868 to 0.922), 0.884 (95% CI, 0.854 to 0.911), and 0.910 (95% CI, 0.882 to 0.933), respectively. Although the high prevalence of VFs in the enrolled cohort partially limits the external validity of the predictive value in the general population, we conclude that the BPIT is potentially effective for detecting painful VFs in back pain populations at risk of osteoporosis. This test may be used as a stratification tool in decision‐making on subsequent imaging procedures: a negative BPIT rules out painful VFs and indicates that an MRI should be spared, whereas a positive BPIT means that an MRI is necessary and is likely to identify painful VFs. © 2019 American Society for Bone and Mineral Research.
Objective In most cases, complete resection of the intradural tumor is accompanied by long‐term neurological complications. Postoperative spinal deformity is the most common complication after surgical resection of intradural tumors, and posterior longitudinal ligament complex (PLC) plays an important role in postoperative spinal deformity. In this study, we investigated the role of PLC in spinal deformity after the surgical treatment of intradural tumors. Methods We analyzed the data of 218 consecutive patients who underwent intradural tumor resection from 2000 to 2018 in this retrospective study. Before 2010, patients underwent laminoplasty without maintaining the integrity of PLC (laminoplasty group, n = 155). After 2010, patients performed single‐port laminoplasty to maintain the integrity of PLC (laminoplasty retain posterior ligament complex group, n = 63). The score of quality of life, painful cortex, spinal cord movement, progressive kyphosis or scoliosis, perioperative morbidity, and neurological results were analyzed in the laminoplasty group and laminoplasty retain posterior ligament complex group. The distributed variable was shown as mean ± standard deviation and an independent t‐test or one‐way analysis of variance was calculated. Results There are 155 patients (71.1%) included in the laminoplasty group, and 63 patients (28.9%) in the laminoplasty retain posterior ligament complex group. The average age of patients was 42 ± 2.3 years, and the average modified McCormick score was 2. There were 158 (72.4%) patients with intramedullary tumors and 115 (52.7%) patients with extramedullary tumors. The length of hospital stays (8 days vs. 6 days; p = 0.023) and discharge to inpatient rehabilitation (48.4% vs. 26.9%; p = 0.012) were significantly lower in the laminoplasty retain posterior ligament complex group than the laminoplasty group. There was no significant difference in the risk of progressive deformity between the two groups at 18 months after surgery (relative risk 0.12; 95% confidence interval [CI] 0.43–1.25; p = 0.258) and at 20 months after surgery (relative risk 0.24; 95% CI 0.21–2.1). Conclusion Laminoplasty retains posterior ligament complex showed no impact on the spinal deformities compared with laminoplasty, but significantly improved the postoperative spinal activity, alleviated pain symptoms, and reduced hospital recovery time.
Study Design. A cross-sectional study. Objective. To quantify the severity of neurogenic intermittent claudication (NIC) for patients with lumbar spinal stenosis (LSS) based on the center of pressure trajectory. Summary of Background Data. NIC is one of the typical symptoms of LSS. So far, the severity level of NIC is mainly evaluated by the subjective description of patients, which might be biased by patients' background differences and thus lead to an ineffective diagnosis or inappropriate treatment for LSS. Therefore, it remains necessary to develop a reliable clinical technique for quantitative evaluation of NIC to achieve more effective therapy for LSS. Materials and Methods. In the present study, the Footscan pressure system was used to detect the center of pressure trajectory. The real-time walking distance (rtWD) and the corresponding displacement of the medial-lateral center of pressure (ML-COP) were calculated based on the trajectory. The differences of ML-COP between LSS and control groups were analyzed using a one-way repeated measures analysis of variance. Regression and Pearson correlation analysis were used to investigate the correlation between rtWD and ML-COP, as well as the relation between the Oxford Claudication Score (OCS) and clinical evaluation indicators.Results. The present study included 31 LSS patients and 31 healthy controls. There were no significant differences in demographic data between the two groups (P > 0.05). The results indicated that ML-COP would increase with the number of laps in the LSS group while not in the control group. Also, a linear relationship was identified between the ML-COP and rtWD for LSS patients (R 2 > 0.80, P < 0.05). Since the incremental rate of ML-COP for LSS patients was reflected by the regression coefficients of the linear regression analysis, thus the regression coefficients were defined as the claudication correlation coefficients (CCCs). In addition, it was indicated by the statistical analysis that there was a strong positive correlation between OCS and CCC (r = 0.96; P < 0.001) and a medium negative correlation with final walking distance (r = −0.67; P < 0.001). It was also noticed that there was no significant correlation between the average ML-COP and OCS (r = −0.03; P = 0.864). Conclusions. The ML-COP of LSS patients would increase with the patients' walking distance. This incremental rate, characterized by the CCC, would be used as an effective indicator to quantify the severity level of the NIC for potentially more accurate and reliable diagnosis, evaluation, and treatment of LSS.
Backgrounds In most cases, complete resection of intranervous tumors and long-term neurological function can be achieved. However, some patients consider progressive postoperative spinal deformity as a postoperative complication. Objective We investigated that the posterior ligament complex obtained during laminoplasty can reduce spinal deformities and improve mobility, pain, and quality of life. Methods We retrospectively reviewed the data of more than 218 consecutive patients who underwent intrascleral tumor resection at one institution. The quality of life, painful cortex, spinal cord movement, progressive kyphosis or scoliosis, perioperative morbidity, and neurological results were compared in the laminoplasty and laminoplasty ligament groups. Results 155 patients underwent laminoplasty and 63 patients underwent ligament complex after laminoplasty. The patient’s age was 42 ± 2.3 years, and the average modified McCormick score was 2. There were 158 (72.4%) intramedullary tumors and 115 (52.7%) extramedullary tumors. The average residence time of the ligament complex after laminoplasty was shortened (8 days vs. 6 days; p = 0.023) and hospital recovery time (48.4% vs. 26.9%; p = 0.012). 8 cases of laminoplasty (3%) and 3 cases of laminoplasty (1%) retained posterior ligament syndrome. Progressive spinal deformities occur an average of 20 months after surgery and an average of 18 months after surgery. Spine deformity. Maintaining the posterior ligament complex during laminoplasty can improve VAS assessment and spinal mobility. Conclusion The treatment of the posterior ligament complex during laminoplasty does not significantly affect spinal deformities, but significantly improves postoperative spinal activity, pain symptoms, and hospitalization.
Objective. To investigate the necessity of nonstructural or structural intraarticular bone grafting in atlantoaxial facet joints via a posterior approach and the influence by presence of basilar invagination (BI).Methods. From November 2016 to October 2018, patients who underwent posterior atlantoaxial or occipitocervical arthrodesis surgery at one institute were retrospectively reviewed. Operation records, preoperative and postoperative clinical status and radiological films were analyzed. Results. 33 patients (19 without BI, 14 with BI) underwent posterior facet joint release followed by intraarticular bone grafting were enrolled finally. 24 nonstructural (15 without BI, 9 with BI) and 9 structural (4 without BI, 5 with BI) grafting were performed. The average follow-up was 32.15±6.73 months (24-47 months). Among them, 1 (3.03%) implant failure occurred, 32 (96.97%) achieved satisfactory neurological outcomes, including 28 (84.85%) complete and 4 (12.12%) acceptable reductions with complete fusion within 6 months. For patients without BI, structural and nonstructural grafting showed no significant difference in terms of reduction maintenance (100% vs 73.33%, p = 0.530), while for those with BI, structural grafting significantly increased the postoperative height of the joint space (5.67±1.22 mm vs 3.43±1.78 mm, p = 0.002) and maintained it much better than nonstructural grafting (88.89% vs 20.00%, p = 0.023), contributing notably to BI correction. Conclusion. Intraarticular structural bone grafting in atlantoaxial facet joints has the advantage of maintaining anterior column height in the case of lateral mass collapse or when BI correction is needed, otherwise, nonstructural bone grafting is enough.
Objective To investigate the necessity of nonstructural or structural intraarticular bone grafting in atlantoaxial facet joints via a posterior approach and the influence by the presence of basilar invagination (BI). Methods From November 2016 to October 2018, patients who underwent posterior atlantoaxial or occipitocervical arthrodesis surgery at one institute were retrospectively reviewed. Operation records, preoperative and postoperative clinical status, and radiological films were analyzed. Results Thirty-three patients (19 without BI, 14 with BI) underwent posterior facet joint release followed by intraarticular bone grafting were enrolled finally. Twenty-four nonstructural (15 without BI, 9 with BI) and 9 structural (4 without BI, 5 with BI) grafting were performed. The average follow-up was 32.15±6.73 months (24–47 months). Among them, 1 (3.03%) implant failure occurred, and 32 (96.97%) achieved satisfactory neurological outcomes, including 28 (84.85%) complete and 4 (12.12%) acceptable reductions with complete fusion within 6 months. For patients without BI, structural and nonstructural grafting showed no significant difference in terms of reduction maintenance (100% vs 73.33%, p = 0.530), while for those with BI, structural grafting significantly increased the postoperative height of the joint space (5.67±1.22 mm vs 3.43±1.78 mm, p = 0.002) and maintained it much better than nonstructural grafting (88.89% vs 20.00%, p = 0.023), contributing notably to BI correction. Conclusion Intraarticular structural bone grafting in atlantoaxial facet joints has the advantage of maintaining anterior column height in the case of lateral mass collapse or when BI correction is needed; otherwise, nonstructural bone grafting is enough.
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