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Study design A retrospective study. Objective To evaluate the different degeneration patterns of paraspinal muscles in degenerative lumbar diseases and their correlation with lumbar spine degeneration severity. Summary of background data The degeneration characteristics of different paraspinal muscles in degenerative lumbar diseases remain unclear. Methods 78 patients diagnosed with single-level degenerative lumbar spondylolisthesis (DLS) and 76 patients with degenerative lumbar kyphosis (DLK) were included as DLS and DLK groups. Paraspinal muscle parameters of psoas major (PS), erector spinae (ES) and multifidus muscle (MF) were measured, including fatty infiltration (FI) and relative cross-sectional area (rCSA), namely the ratio of the paraspinal muscle CSA to the CSA of the vertebrae of the same segment. Sagittal parameters including lumbar lordosis (LL) and sagittal vertical axis (SVA) were measured. The paraspinal muscle parameters and ES/MF rCSA ratio were compared between the two groups. Paraspinal muscles parameters including rCSA and FI were also compared between each segments from L1 to L5 in both DLS and DLK groups. In order to determine the influence of sagittal spinal alignment on paraspinal muscle parameters, correlation analysis was conducted between the MF, ES, PS rCSA and FI and the LL in DLS and DLK group. Result MF atrophy is more significant in DLS patients compared with DLK. Also, MF fatty infiltration in the lower lumbar spine of DLS patients was greater compared to DLK patients. DLK patients showed more significant atrophy of ES and heavier ES fatty infiltration. MF FI was significantly different between all adjacent segments in both DLS and DLK groups. In DLS group, ES FI was significantly different between L2/L3 to L3/L4 and L4/L5 to L5/S1, while in DLK group, the difference of ES FI between all adjacent segments was not significant, and ES FI was found negatively correlated with LL. Conclusions Paraspinal muscles show different degeneration patterns in degenerative lumbar diseases. MF degeneration is segmental in both DLS and DLK patients, while ES degenerated diffusely in DLK patients and correlated with the severity of kyphosis. MF degeneration is more significant in the DLS group, while ES degeneration is more significant in DLK patients. MF is the stabilizer of the lumbar spine segments, while the ES tends to maintain the spinal sagittal balance.

To our knowledge, laminectomy with fusion (LCF) and laminoplasty alone (LP) are both effective posterior surgical approaches for decompression of cervical spondylotic myelopathy (CSM). However, which one is suitable for patients has no standard answer. This study estimated whether the ratio of C2-C7 Cobb angle to T1 slope (CL/T1S) could be an indication of posterior surgical approach.We retrospectively reviewed 128 patients with at least 6 months of follow-up who underwent LCF or LP. Radiological measurements, including C2-C7 Cobb angle, decompressed Cobb angle, T1 slope, cervical sagittal vertical axis, and curvature index (CI), and clinical outcomes, including Japanese Orthopedic Association score and visual analogue scale were evaluated. ROC curve analysis was used to identify discriminative power of CL/T1S ratio to predict kyphotic deformity and severe lordosis loss. The t-test and Mann-Whitney U-test were used to evaluate the difference between LCF and LP. Kruskal-Wallis H - test and ANOVA were used to evaluate the difference among different ratio CL/T1S groups.The cervical lordosis decreased after LCF or LP (p 0.001, p 0.001, respectively). Based on ROC curve analysis, CL/T1S ratio had a good discriminative power to predict kyphotic deformity and severe lordosis loss (AUC = 0.70, AUC = 0.88, respectively). According to CI value changes, cervical lordosis losses in group LP were larger than that in group LCF (p = 0.006). However, there was no significant difference in CI changes of fair-ratio CL/T1S group between LCF and LP. For patients with low CL/T1S ratio or high CL/T1S ratio, CI changes in group LP were greater than that in group LCF (p = 0.037, p = 0.042, respectively).CL/T1S ratio could be an indication of posterior surgical approach. Compared with LP, LCF reduces postoperative cervical lordosis losses in low-ratio and high-ratio CL/T1S groups.

Cervical deformity (CD) is a kind of disorder influencing cervical alignment. Although the incidence of CD is not high, this deformity can cause not only pain but also difficulties in daily activities such as swallowing and maintaining upright position. Even though the common cause of cervical deformity is still controversial, previous studies divided CD into congenital deformity and secondary deformity; secondary deformity includes iatrogenic and noniatrogenic deformity according to pathogenic factors. Due to the lack of relevant studies, a standardized evaluation for CD is absent. Even though the assessment of preoperative condition and surgical planning mainly rely on personal experience, the evaluation methods could still be summarized from previous studies. The objective in this article is to summarize studies on cervical scoliosis, identify clinical problems, and provide directions for researchers interested in delving deep into this specific topic. In this review, we found that the lack of standard classification system could lead to an absence of clinical guidance; in addition, the osseous landmarks and vascular distributions could be variable in CD patients, which might cause the risk of vascular or neurological complications; furthermore, multiple deformities were usually presented in CD patients, which might cause chain reaction after the correction of CD; this would prevent surgeons from choosing realignment surgery that is effective but risky.

Study design Retrospective case–control study. Objectives Proximal junctional kyphosis (PJK) is a postoperative complication involving the proximal segments which is commonly seen in patients with degenerative spine diseases (DSD). The purpose of the present study was to identify predictive factors for postoperative PJK in elderly patients with DSD. Methods We reviewed elderly patients with DSD who underwent thoracolumbar fusion involving no less than 3 levels. Patients who developed PJK were propensity score-matched with patients with DSD who received the same procedure but did not develop PJK. Demographic characteristics, sagittal vertical axis (SVA), computed tomography (CT) value (Hounsfield unit), and paraspinal muscle parameters were compared between PJK and non-PJK groups. Results Eighty-three PJK and non-PJK patients were selected by propensity score matching for age, sex, history of smoking, body mass index, number of fused segments, and upper instrumented vertebra (UIV) location. SVA showed no significant difference between the two groups. In PJK group, fatty infiltration (FI) in erector spinae and multifidus was significantly greater, while the relative cross-sectional area (rCSA) of erector spinae was significantly smaller than that in non-PJK group. CT value was significantly lower in PJK group. Lower erector spinae rCSA and CT value of the UIV, higher erector spinae FI and multifidus FI were identified as predictors of postoperative PJK. Conclusions PJK is a common complication in older patients with DSD. Paraspinal muscle degeneration and low bone mineral density of the UIV are predictors of PJK. Protective measures targeting paraspinal muscles and the UIV may help prevent postoperative PJK.

Study design Multivariate analysis of retrospective registry data. Objective To report the perioperative complication in a large cohort of surgery for elderly degenerative lumbar scoliosis (DLS) patients and to analyze the risk factors. Summary of background data The perioperative complication rate and risk factors for patients with DLS remain unclear, especially in elderly population. Methods Between November 2015 and June 2018, 98 patients aged 70 or older with DLS received decompression and intervertebral fusion by one spine surgeon at Beijing Xuanwu Hospital. The medical history and comorbidities of all patients were recorded. Results The perioperative complication rate was 34.7% in all patients, 11.2% of all patients had major complications, and 31.6% had minor complications. The major complication most commonly seen was wound infection, and the most common minor complication was hypoproteinemia. Elderly patients (>75) had longer hospital stays (17.5 ± 7.9) when compared to younger patients. Two risk factors of perioperative complications were chosen after binary logistic regression analysis: lower BMI and longer instrumented segments. The only risk factor for major complications was longer instrumented level (≥3), and the only risk factor for minor complications was lower BMI. Conclusion Our findings indicate that in elderly patients with DLS, lower BMI is a risk factor for minor perioperative complication. Obesity is not a major problem in this population, on the contrary, BMI is a protective factor for perioperative complications. The risk factors for major perioperative complications in elderly patients with DLS are longer instrumented segments but not related to the number of decompression and intervertebral fusion levels. Preoperative comorbidities and advanced age were not associated to a higher perioperative complication rate in elderly patients. The perioperative complication rate in patients with DLS over 70 years of age is found to be acceptable with appropriate perioperative management.

To report the perioperative complication rates in elderly patients undergoing lumbar arthrodesis and to analyze the risk factors.Between September 2015 and June 2018, 215 patients aged ≥70 underwent posterior lumbar arthrodesis with pedicle screw fixation. Demographic data including age, gender, smoking status, body mass index (BMI) and preoperative comorbidities were collected. Operative records as the number of levels fused, estimated blood loss, time of surgery, and the occurrence of perioperative complications were reviewed. Risk factors of perioperative complications were determined by logistic regression analysis.The total perioperative complication rate in all patients was 30.2%, of which major complications occurred in 24 patients (11.2%) and minor complications occurred in 41 patients (19.1%). Two risk factors of perioperative complications (major or minor) were chosen: BMI (cutoff value 24.32) and surgical level (≥3). Lower surgical level (≥3) and smaller BMI were risk factors for perioperative minor complications, and major complication was affected only by surgical level (≥3).The risk factor of perioperative complication in elderly patients after lumbar arthrodesis was fusion segment (≥3), and BMI was a protective factor. Elderly patients with BMI24.32 are more likely to have perioperative complications after lumbar arthrodesis.

BACKGROUND This is the first published study assessing the parallelogram effect of degenerative structures around the apical vertebra. We evaluated the effect of degenerative structures around the apical vertebra and spinopelvic parameters on the severity of ADS. MATERIAL AND METHODS We retrospectively reviewed data on 144 patients with ADS. The coronal (coronal Cobb angle, CA) and sagittal (thoracic kyphosis, TK; sagittal vertical axis, SVA; pelvic incidence, PI; lumbar lordosis, LL; sacral slope, SS; pelvic tilt, PT) parameters, lumbar multifidus muscle atrophy (LMA), and facet joint osteoarthritis (FJOA) were evaluated. Multiple linear regression was used to assess the correlations. RESULTS LL and PT were negatively correlated with CA (P

Background. The mechanisms and risk factors for proximal junctional kyphosis of elderly patients may differ from those of non-elderly patients. The risk factors for PJK in the elderly population remain unclear. Methods. The present study enrolled elderly DSD patients over 65 years of age who underwent thoracolumbar fusion with no less than 3 levels fused. All patients underwent CT and MRI scans preoperatively, and full spine standing X-ray preoperatively, postoperatively and during follow-up with a minimum follow-up of 18 month. Paraspinal muscle cross-sectional area(CSA) and paraspinal muscle fatty infiltration(FI) of erector spinae(ES) and multifidus muscle(MF), LL, PI, PT, SS, PI-LL and vertebra CT HU value were measured. Radiological PJK was defined as a sagittal Cobb angle between the UIV and the two levels above the UIV (UIV+2) of 10° or greater and at least 10° greater than the preoperative measurement. Parameters were compared between PJK and Non-PJK patients.Result. A total of 259 patients were enrolled. The prevalence of PJK was 35.9%. Compared with Non-PJK group, PJK group had significantly older age at surgery, greater BMI, lower vertebra CT value and greater PI and a larger PI-LL mismatch. Both erector spinae(ES) and multifidus muscle(MF) relative cross-sectional area(rCSA) of PJK patients were significantly smaller, the ES and MF fatty infiltration(FI) were significantly greater than the Non-PJK patients. Older age at surgery, greater BMI, greater PI, smaller MF rCSA, greater ES and MF FI and smaller CT value were independent risk factors for PJK in elderly patient population.Conclusions. For elderly patients with DSD, PJK is a commonly seen complication. Higher age at surgery, larger BMI, significant paraspinal muscle degeneration and low bone mineral density are risk factors for PJK. Appropriate preoperative and postoperative measures are beneficial for reducing the risk of PJK in the elderly.

To determine whether clinical characteristics and signal and morphologic changes on magnetic resonance (MR) images of the spinal cord (SC) are associated with surgical outcomes for cervical spondylotic myelopathy (CSM).A total of 113 consecutive patients with cervical myelopathy underwent cervical decompression surgery in our hospital from January 2015 to January 2018. All patients with preoperative MR images available for review were recruited for this study. Research data included patient sex, age, duration of symptoms, surgical approach, compression level, preoperative mJOA (modified Japanese Orthopaedic Association) score, postoperative mJOA recovery rate, and complications. Imaging data included signal changes on T2-weighted MRI images (grade and extension on sagittal images, four types of signal changes on axial images according to the Ax-CCM system), SC compression, transverse area of the SC, and compression ratio. The t-test, Mann-Whitney U-test, Kruskal-Wallis H - test, analysis of variance, and regression analysis were used to evaluate the effects of individual predictors on surgical outcomes.The study cohort included 85 males and 27 females with a mean age of 60.92 ± 8.93 years. The mean mJOA score improved from 10.24 ± 1.69 preoperatively to 15.11 ± 2.05 at the final follow-up (p 0.001). Patients in the poor outcome group were more likely to present with a longer duration of symptoms (p 0.001) and smaller transverse area of the SC (p 0.001). Bright T2-weighted high signal changes (T2HSCs), multisegmental high signal changes on sagittal MR images, and fuzzy focal T2HSCs on axial MR images were associated with a poor outcome (p0.001, p = 0.005, p 0.001, respectively). The maximum SC compression and compression ratio were not reliable predictors of surgical outcomes (p = 0.375, p = 0.055, respectively). The result of multivariate stepwise logistic regression showed that a longer duration of symptoms, multisegmental T2HSCs on sagittal MR images and fuzzy focal T2HSCs on axial MR images were significant risk factors of poor outcomes (p0.001, p = 0.049, p = 0.016, respectively).A longer duration of symptom, multisegmental T2HSCs on sagittal MR images, and fuzzy focal T2HSCs on axial MR images were highly predictive of a poor surgical outcome for CSM. Smaller transverse area of the SC and bright T2HSCs were also associated with the prognosis of CSM.

This study evaluated survival outcomes of patients with intramedullary Grade II ependymomas and identify prognostic factors. Electronic searches of PubMed, EMBASE, OVID, the Cochrane Central Register of Controlled Trials were performed to identify trials according to the Cochrane Collaboration guidelines. The objects were intramedullary Grade II ependymoma according to 2007 WHO classification. Kaplan-Meier survival analysis with log-rank test was used to analyze progressive free survival (PFS) and overall survival (OS). Cox proportional hazard model was utilized for multivariate analysis with hazard ratio (HR) and 95% confidence interval (CI) calculated. P values

Supplemental Digital Content is available in the text, Background: The difference between topping-off technique and posterior lumbar interbody fusion (PLIF) in postoperative outcomes is still controversial. The aim of this study is to compare all available data on outcomes of topping-off technique and PLIF in the treatment of chronic low back pain. Methods: Articles in PubMed, EMBASE and Cochrane were reviewed. Parameters included radiographical adjacent segment disease (RASD), clinical adjacent segment disease, range of motion (ROM), global lumbar lordosis (GLL), visual analog scale (VAS), visual analog scale of back, (VAS-B) and visual analog scale leg (VAS-L), Oswestry disability index, Japanese Orthopaedic Association (JOA) score, duration of surgery, estimated blood loss (EBL), reoperation rates, complication rates. Results: Rates of proximal RASD (P = .001) and CASD (P = .03), postoperative VAS-B (P = .0001) were significantly lower in topping-off group than that in PLIF group. There was no significant difference in distal RASD (P = .07), postoperative GLL (P = .71), postoperative upper intervertebral ROM (P = .19), postoperative VAS-L (P = .08), DOI (P = .30), postoperative JOA (P = .18), EBL (P = .21) and duration of surgery (P = .49), reoperation rate (P = .16), complication rates (P = .31) between topping-off group and PLIF. Conclusions: Topping-off can effectively prevent the adjacent segment disease from progressing after lumbar internal fixation, which is be more effective in proximal segments. Topping-off technique was more effective in improving subjective feelings of patents rather than objective motor functions. However, no significant difference between topping-off technique and PLIF can be found in the rates of complications.

BackgroundProper reduction method for Lumbar degenerative spondylolisthesis (LDS) is still controversial. The aim of this study was to determine the safety and effectiveness of lever reduction combined with traditional elevating-pull reduction technique for the treatment of elderly patients with LDS.MethodsFrom May 2015 to December 2017, 142 elderly patients (≥65 years) diagnosed with LDS were enrolled in this study with a mean follow-up of 25.42 ± 8.31 months. All patients were operated using lever reduction combined with traditional elevating-pull reduction technique. Patient age, sex, body mass index, bone mineral density, preoperative comorbidities, surgical duration, blood loss, and surgical complications were collected form patient charts. Clinical data as visual analog scale (VAS), Oswestry Disability Index (ODI), and 36-Item Short Form Health Survey (SF-36) were collected preoperatively, 1 month postoperatively, and at the final follow-up. Radiographic evaluation included slip percentage, slip angle (SA), lumbar lordosis (LL), and fusion status.ResultsThe clinical parameters of VASback, VASleg, ODI, and SF-36 had significantly improved at both follow-ups after surgery. A significant improvement was indicated for slippage reduction at both follow-ups, showing no significant correction loss after surgery. SA significantly increased after surgery and was well maintained at the final follow-up. LL was not affected by the surgery. At the final follow-up, complete fusion was obtained in 121 patients (85.2%) and partial fusion in 21 (14.8%). Revision surgery was performed for one patient. Screw loosening was observed in 3 (2.11%) cases. No nerve root injury or adjacent segment disease was observed.ConclusionsThis new lever reduction combined with traditional elevating-pull reduction technique for the surgical treatment of elderly patients with LDS is both safe and effective. Satisfactory correction and fusion rates were achieved with acceptable correction loss and reduction-related complications.

Background The aim of this study was to compare the reliability and validity of the CARDS and French classification systems for lumbar DS. Methods Between May 2013 and December 2016, 158 consecutive patients diagnosed with single-level lumbar DS were included in this study, and all underwent lumbar fusion. All patients underwent long-cassette standing anterioposterior and lateral radiographs of the spine preoperatively and postoperatively. The images were graded according to the CARDS and French classification systems by two orthopedic spinal surgeons and two orthopedic spinal fellows, independently. Clinical outcome measures used were the visual analog scale, Oswestry Disability Index, and the 36-Item Short Form Health Survey. Clinical data were collected before surgery and 1 year after surgery. Results A total of 146 patients were finally included in this study and followed up for at least 1 year. When grading using the CARDS system, the κ values for inter- and intraobserver reliability were 0.837 and 0.869, respectively, representing perfect agreement. The interobserver κ value for the French classification was 0.693 and the intraobserver κ value was 0.743, both representing substantial agreement. CARDS Type D patients have higher preoperative back pain scores and better improvement after surgery compared with non-Type D patients. Mean back and leg pain was worse in French Type 5 patients, while the most significant improvement was also seen in Type 5 patients after surgery. Conclusions Both CARDS and French classification systems have acceptable reliability and validity. The CARDS system is easier to utilize and has better reliability. Level of evidence IV

Background There were several reports describing the biomechanics and microstructure of multifidus muscles in patients with lumbar disc herniation. However, correlations between lumbar multifidus muscle atrophy (LMA), spinopelvic parameters, and severity of adult degenerative scoliosis (ADS) have not been investigated. The study evaluated the impact of LMA and spinopelvic parameters on the severity of ADS. Methods One hundred and thirty-two patients with ADS were retrospectively reviewed. Standing whole-spine X-ray was used to evaluate the coronal (coronal Cobb angle, CA; coronal vertical axis, CVA) and sagittal (sagittal vertical axis, SVA; thoracic kyphosis, TK; lumbar lordosis, LL; pelvic incidence, PI; pelvic tilt, PT; sacral slope, SS) parameters. LMA was evaluated on axial T2-weighted magnetic resonance imaging (MRI) at intervertebral levels above and below the vertebra at the apex of the scoliotic curve. Clinical symptoms were evaluated by the Oswestry Disability Index (ODI) and the Japanese Orthopaedic Association (JOA) score. Multiple linear regression was used to assess correlations between LMA, spinopelvic parameters, and severity of scoliosis. Results LL and PT were negatively correlated with CA (P

To assess the relationship between the ratio of C2-C7 Cobb angle to T1 slope (CL/T1S) and cervical alignment changes after laminoplasty.78 consecutive patients with cervical myelopathy who underwent laminoplasty were enrolled. All patients with preoperative and follow-up cervical spine lateral x-ray images available for review were recruited in this study. Imaging data included C2-C7 Cobb angle, T1 slope, and cervical sagittal vertical axis (cSVA). All patients were classified into low-ratio group (bottom 25% of CL/T1S), fair-ratio group (middle 50% of CL/T1S), and high ratio group (top 25% of CL/T1S) according to CL/T1S ratio. The recovery rate was calculated based on the Japanese Orthopedic Association score.The preoperative C2-C7 Cobb angle had significant correlations with the T1 slope (r = 0.528). Kyphotic alignment changes in the group with a high ratio of CL/T1S was greater than that of the other 2 groups (P0.001). The incidence of postoperative kyphosis in the group with a low ratio of CL/T1S was higher than that of the other 2 groups (P0.001). There was no postoperative kyphosis in the fair-ratio group. The surgical outcome in the low-ratio CL/T1S group and the high-ratio CL/T1S group was poorer than that in the fair-ratio CL/T1S group (P = 0.005).The cervical alignment was kept well in the mid-range CL/T1S ratio group after laminoplasty. Patients with a high CL/T1S ratio were more likely to present with kyphotic alignment changes. Patients with a low CL/T1S ratio were more likely to have postoperative kyphosis.

Background Most of the previous studies combined all types of intramedullary ependymomas without providing accurate pathological subtypes. In addition, it was very difficult to evaluate the factors associated with postoperative outcomes of patients with different pathological subtypes of intramedullary Grade II ependymomas by traditional meta-analysis. This study evaluated the factors related with postoperative outcomes of patients with intramedullary Grade II ependymomas. Methods Individual patient data analysis was performed using PubMed, Embase, and the Cochrane Central Register of Controlled Trials. The search included articles published up to April 2018 with no lower date limit on the search results. The topics were intramedullary Grade II ependymomas. Progression-free survival (PFS) and overall survival (OS) were analyzed by Kaplan-Meier survival analysis (log-rank test). The level of significance was set at P Results A total of 21 studies with 70 patients were included in this article. PFS of patients who underwent total resection was much longer than the PFS of those who received subtotal resection (P Conclusions PFS of patients who received total resection was much longer than those who received subtotal resection. Patients treated with adjuvant therapy or radiotherapy and chemotherapy appeared to have shorter PFS than others; PFS of patients with cerebrospinal fluid disease dissemination or scoliosis were significantly shorter than others. Cellular ependymomas would have better OS than giant cell ependymoma. However, giant cell ependymoma patients might have the worst OS.