Outcomes of Surgery for Thoracic Myelopathy Owing to Thoracic Ossification of The Ligamentum Flavum in a Nationwide Multicenter Prospectively Collected Study in 223 Patients: Is Instrumented Fusion Necessary?
在一项全国多中心前瞻性收集的 223 例患者研究中，胸椎黄韧带骨化症所致胸椎脊髓病的手术结局: 是否需要器械融合？
- 作者列表："Ando K","Imagama S","Kaito T","Takenaka S","Sakai K","Egawa S","Shindo S","Watanabe K","Fujita N","Matsumoto M","Nakashima H","Wada K","Kimura A","Takeshita K","Kato S","Murakami H","Takeuchi K","Takahata M","Koda M","Yamazaki M","Watanabe M","Fujibayashi S","Furuya T","Kawaguchi Y","Matsuyama Y","Yoshii T","Okawa A
STUDY DESIGN:Prospectively collected, multicenter, nationwide study. OBJECTIVE:The aim of this study was to investigate recent surgical methods and trends, outcomes, and perioperative complications in surgery for thoracic ossification of the ligamentum flavum (T-OLF). SUMMARY OF BACKGROUND DATA:A prospective multicenter study of surgical complications and risk factors for T-OLF has not been performed, and previous multicenter retrospective studies have lacked details for these items. METHODS:Surgical methods, pre- and postoperative thoracic myelopathy (Japanese Orthopedic Association [JOA] score), symptoms, and intraoperative neurophysiological monitoring were investigated prospectively in 223 cases. Differences in these factors between fusion and nonfusion procedures for T-OLF were examined. The minimum follow-up period was 2 years after surgery RESULTS.: The mean JOA score was 6.2 points preoperatively, and 7.9, 8.2, and 8.2 points at 6 months, 1, and 2 year postoperatively, giving mean recovery rates of 35.0%, 40.9%, and 41.4% respectively. Posterior decompression and fusion with instrumentation was performed in 109 cases (48.9%). There were 45 perioperative complications in 30 cases (13.5%), with aggravation of motor disturbance in the lower extremities being most common (4.0%, n = 9). Patients treated with fusion had a significantly higher BMI, rate of gait disturbance, ossification occupation rate of OLF at computed tomography, and intramedullary high intensity area at magnetic resonance imaging (P < 0.01). The preoperative JOA score was lower (P < 0.05) and the JOA recovery rate at 1 year after surgery was significantly higher in cases treated without fusion (44.9% vs. 37.1%, P < 0.05). CONCLUSION:The high rate of surgery with instrumentation of 48.9% reflects the current major trend toward posterior instrumented fusion surgery for T-OLF. Fusion surgery with instrumentation may be appropriate for patients with severe OLF and preoperative myelopathy. A further prospective study of long-term outcomes is required with a focus on optimal surgical timing and the surgical procedure for T-OPLL. LEVEL OF EVIDENCE:3.
研究设计: 前瞻性收集、多中心、全国性研究。 目的: 本研究的目的是探讨胸椎黄韧带骨化症 (T-OLF) 手术的近期手术方法和趋势、疗效和围手术期并发症。 背景资料摘要: 尚未进行T-OLF手术并发症和危险因素的前瞻性多中心研究，以前的多中心回顾性研究缺乏这些项目的细节。 方法: 前瞻性研究了 223 例患者的手术方法、术前和术后胸椎脊髓病 (日本骨科协会 [JOA] 评分) 、症状和术中神经电生理监测。检查了T-OLF融合和非融合手术之间这些因素的差异。手术结果后最短随访时间为 2 年。:术前平均JOA评分为 6.2 分，术后 6 个月、 1 年和 2 年平均JOA评分为 7.9 分、 8.2 分和 8.2 分，平均恢复率为 35.0% 、 40.9% 、和 41.4%。后路减压植骨融合术 109 例 (48.9%)。围手术期并发症 45 例 (13.5%)，以下肢运动障碍加重最常见 (4.0%，n = 9)。接受融合治疗的患者BMI、步态紊乱率、计算机断层扫描时OLF的骨化占领率和磁共振成像时髓内高强度区域显著升高 (p <0.01)。术前JOA评分较低 (p <0.05)，未接受融合治疗的病例术后 1 年JOA治愈率明显较高 (44.9% vs. 37.1%，p <0.05)。 结论: 器械手术率高达 48.9%，反映了目前T-OLF后路器械融合手术的主要趋势。器械融合手术可能适用于严重OLF和术前脊髓病患者。需要进一步的长期结局前瞻性研究，重点关注T-OPLL的最佳手术时机和手术方式。 证据级别: 3.
METHODS:BACKGROUND:Postoperative cognitive dysfunction (POCD) is a common complication after orthopedic surgery, which is not conducive to the prognosis of the elderly. AIMS:We performed this study to investigate the effects of oxycodone applied for patient-controlled intravenous analgesia (PCIA) on postoperative cognitive function in elderly patients after total hip arthroplasty (THA). METHODS:Ninety-nine participants were enrolled and allocated into two groups: oxycodone group (group O) and sufentanil group (group S). The primary outcome was the incidence of POCD, diagnosed according to the changes in the Mini-mental status examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores. The secondary outcomes included the plasma levels of S-100B protein and neuron-specific enolase (NSE), the amount of postoperative analgesic consumption and the incidence of adverse reactions. RESULTS:The incidence of POCD was significantly lower in patients receiving oxycodone up to the 3rd postoperative day (POD, 1st POD 27.3% vs. 51.1%, P = 0.021; 3rd POD 20.5% vs. 40.0%, P = 0.045), as compared to patients receiving sufentanil. The MMSE and MoCA scores of both groups decreased to varying degrees. However, compared with group S, the MMSE scores at 1st POD, 3rd POD, 5th POD and 7st POD in group O were higher than that in group S, while MoCA scores at 1st POD, 3rd POD and 5th POD in group O were higher. Compared with group S, the plasma levels of S-100B protein in group O at 4 h, 8 h, 12 h post-surgery were lower. While the plasma levels of NSE in group O at 4 h, 8 h, 12 h, 24 h post-surgery were lower. Number of PCIA boluses and consumption of analgesic drug during the first two POD were similar between two groups. However, postoperative incidence of nausea, vomiting and pruritus was significantly lower in patients receiving oxycodone. CONCLUSION:Oxycodone applied for PCIA in elderly patients after THA could reduce the incidence of POCD, improve postoperative cognitive function and decrease the adverse reactions.
METHODS:BACKGROUND:Primary treatment for Blount disease has changed in the last decade from osteotomies or staples to tension band plate (TBP)-guided hemiepiphysiodesis. However, implant-related issues have been frequently reported with Blount cases. The purpose of our study is to evaluate the surgical failure rates of TBP in Blount disease and characterize predictors for failure. METHODS:We performed an Institutional Review Board-approved retrospective chart-review of pediatric patients with Blount disease to evaluate the results of TBP from 2008 to 2017 and a systematic literature review. Blount cases defined as pathologic tibia-vara with HKA (hip-knee-ankle) axis and MDA (metaphyseal-diaphyseal angle) deviations ≥11 degrees were included in the analysis. Surgical failure was categorized as mechanical and functional failure. We studied both patient and implant-related characteristics and compared our results with a systematic review. RESULTS:In 61 limbs of 40 patients with mean follow-up of 38 months, we found 41% (25/61) overall surgical failure rate and 11% (7/61) mechanical failure rate corresponding to 11% to 100% (range) and 0% to 50% (range) in 8 other studies. Statistical comparison between our surgical failure and nonfailure groups showed significant differences in deformity (P=0.001), plate material (P=0.042), and obesity (P=0.044) in univariate analysis. The odds of surgical failure increased by 1.2 times with severe deformity and 5.9 times with titanium TBP in the multivariate analysis after individual risk-factor adjustment. All 7 mechanical failures involved breakage of cannulated screws on the metaphyseal side. CONCLUSIONS:Most of the studies have reported high failure rates of TBP in Blount cases. Besides patient-related risk factors like obesity and deformity, titanium TBP seems to be an independent risk factor for failure. Solid screws were protective for mechanical failure, but not for functional failure. In conclusion, efficacy of TBP still needs to be proven in Blount disease and implant design may warrant reassessment. LEVEL OF EVIDENCE:Level III-retrospective comparative study with a systematic review.
METHODS:INTRODUCTION:As cancer treatments continue to improve the overall survival rates, more patients with a history of cancer will present for anatomic total shoulder arthroplasty (TSA). Therefore, it is essential for orthopaedic surgeons to understand the differences in care required by this growing subpopulation. Although the current research suggests that good outcomes can be predicted when appropriately optimized patients with cancer undergo lower extremity total joint arthroplasty, similar studies for TSA are lacking. The primary study question was to examine whether a history of cancer was associated with an increased rate of venous thromboembolism (VTE) after TSA. Secondarily, we sought to examine any association between a history of prostate and breast cancer and surgical or medical complications after TSA. METHODS:Using a national insurance database, male patients with a history of prostate cancer and female patients with a history of breast cancer undergoing anatomic TSA for primary osteoarthritis were identified and compared with control subjects matched 3:1 based on age, sex, diabetes mellitus, and tobacco use. Patients with a history of VTE and patients who underwent reverse TSA or hemiarthroplasty were excluded. RESULTS:Female patients with a history of breast cancer and male patients with a history of prostate cancer undergoing TSA had significantly higher incidences of acute VTE (including deep venous thrombosis and pulmonary embolism) compared with matched control subjects (female patients: odds ratio, 1.41; 95% confidence interval, 1.10 to 1.81; P = 0.024 and male patients: odds ratio, 1.37; 95% confidence interval, 1.05 to 1.79; P = 0.023). No significant differences were noted in the incidences of any other complications assessed. CONCLUSION:Although a personal history of these malignancies does represent a statistically significant risk factor for acute VTE after anatomic TSA, the overall VTE rate remains modest and acceptable. The rates of other surgical and medical complications are not significantly increased in patients with a history of these cancers after TSA compared with control subjects.