Risk Factors for Reintubation After Anterior Cervical Spine Surgery: Comparative Study of Patients With Cervical Spine Trauma and Patients With Cervical Degenerative Disease.

STUDY DESIGN: Single-center retrospective study. OBJECTIVES: The aim was to compare the postoperative outcomes of anterior cervical spine surgery (ACSS) in patients with and without cervical spine trauma. SUMMARY OF BACKGROUND: Few papers have addressed airway obstruction after anterior ACSS for patients with cervical spine trauma. This study aimed to compare airway obstruction after ACSS between patients with cervical degenerative disorders and cervical spine injuries and identify the risk factors for unplanned postoperative reintubation. MATERIALS AND METHODS: Seventy-seven patients who underwent ACSS were enrolled in this retrospective study. There were 52 men and 25 women, with a mean age of 60.3±15.5 years old. The causes of surgery were as follows: 24 cervical spine fractures or dislocations, 12 spinal cord injuries without bony fracture, 19 disc herniations, and 22 myelopathies. The patients' characteristics, operative data, and risk factors for unplanned reintubation within 5 days postoperatively were analyzed using medical records. RESULTS: Postoperative reintubation was performed in 3 patients (3.9%), all of whom suffered trauma. We further examined risk factors for reintubation in patients in the trauma group. There was no significant difference between the reintubation (R) and nonreintubation (non-R) groups in age, sex, body mass index, amount of blood loss and operation time, preoperative paralysis severity, and the number of fused segments. Patients in group R had significantly higher rates of severe anterior element injury (100% vs. 27.3%, P=0.0011). Airway obstruction due to laryngopharyngeal edema and swelling was confirmed by laryngoscopy and computed tomography images. CONCLUSIONS: Unplanned reintubation after ACSS occurred at a higher rate in trauma patients than in patients with degenerative disorders. Our results suggested that the severe damage to the anterior element of the cervical spine was associated with postoperative reintubation. EVIDENCE LEVEL: Level IV.

Correction loss following short-segment posterior fixation for traumatic thoracolumbar burst fractures related to endplate and intervertebral disc destruction.

BACKGROUND: There has been widespread use of short-segment posterior fixation (SSPF) for traumatic thoracolumbar burst fractures. The relationship between the destruction of the vertebral endplate and adjacent disc and postoperative correction loss has been studied in only a few studies. This study investigated the risk factors for correction loss following SSPF. METHODS: Forty-eight patients (mean age 35.0 years) who underwent SSPF for thoracolumbar burst fractures were enrolled. The mean follow-up period was 25.7 months (12-98 months). The neurological status and postoperative back pain were assessed by the medical records. Segmental kyphotic angle (SKA) and anterior vertebral body height ratio (AVBHR) were measured radiographically to assess indirect vertebral body reduction and local kyphosis. Preoperative Sander's traumatic intervertebral disc lesion (TIDL) classification and AO classification were used to evaluate the severity of disc and vertebral endplate injury. The corrective loss was considered present if ΔSKA was ≥10°. A multivariate logistic regression analysis was performed to identify the risk factors associated with postoperative loss of correction. RESULTS: The fracture distribution was as follows: 10 at T12, 17 at L1, 10 at L2, 9 at L3, and 2 at L4. Vertebral fractures were classified in the following way: A3 in 13 patients, A4 in 11, B1 in 11, and B2 in 13. In 47 patients (98%), a union of the fractured vertebrae was achieved. SKA and AVBHR improved significantly after surgery from 11.6° to 3.5° and from 67.2 to 90.0%, respectively. However, the correction loss at follow-up was 10.4° and 9.7%, respectively. Twenty patients (42%) had severe TIDL (grade 3). Postoperative ΔSKA and ΔAVBHR were significantly higher in patients with TIDL grade 3 than with TIDL grade 0-2. The presence of cranial TIDL grade 3 and older age were significant risk factors for ΔSKA ≥10° on multivariate logistic regression analysis. All patients could walk at follow-up. TIDL grade 3 and ΔSKA ≥10° were associated with severe postoperative back pain. CONCLUSIONS: Risk factors for loss of correction after SSPF for thoracolumbar burst fractures were severe disc and endplate destruction at the time of injury and older age.

Association of preoperative muscle composition of the lower extremity with gait function after total knee arthroplasty.

BACKGROUND: Limitations of gait function persist in some patients with knee osteoarthritis after total knee arthroplasty. This study aimed to identify preoperative muscle composition variables of the operated limb associated with postoperative gait function. METHODS: Longitudinal data from 45 patients who underwent unilateral primary total knee arthroplasty were retrospectively analyzed. Timed Up-and-Go test and gait speed were measured preoperatively and at 3 and 6 months postoperatively. Preoperative muscle composition in the glutei medius and minimus, the quadriceps, the hamstrings, and combination of the hamstrings and quadriceps were evaluated by computed tomography. The area ratio of the individual muscle composition to the total muscle was calculated. The factors associated with Timed Up-and-Go test and gait speed were identified using stepwise regression analysis. RESULTS: Shorter Timed Up-and-Go test and faster gait speed at each time point correlated with higher lean muscle mass area of the total hamstrings, higher area ratio of lean muscle mass to the total hamstrings or to combination of the hamstrings and quadriceps, and lower area ratio of low density lean tissue or intramuscular adipose tissue to the total hamstrings. Shorter Timed Up-and-Go test at each time point also correlated with higher combined area of lean muscle mass of the hamstrings and quadriceps. Faster gait speed at each time point additionally correlated with lower area ratio of intramuscular fat to the total hamstrings and lower area ratio of lean tissue mass or intramuscular adipose tissue to combination of the hamstrings and quadriceps. Regression analysis using the significant muscle composition variables revealed that the area ratio of lean muscle mass to the total hamstrings was the only predictor of Timed Up-and-Go test and gait speed after operation. CONCLUSIONS: Preoperative area ratio of ipsilateral lean muscle mass to the total hamstrings could predict gait function after total knee arthroplasty.

The Efficacy and Complications of Preoperative Embolization of Metastatic Spinal Tumors: Risk of Paralysis after Embolization.

Introduction: This study investigated the efficacy and complications of preoperative embolization for spinal metastatic tumors, focusing on the etiology of post-embolization paralysis. Methods: We retrospectively reviewed the data of 44 consecutive patients with spinal metastases treated between September 2012 and December 2020. Intraoperative blood loss and postoperative transfusion requirement were compared between the embolization (+) and (-) groups. Complications associated with embolization were reviewed. Results: Overall, 30 patients (68%) underwent preoperative embolization. All the patients in both groups underwent palliative posterior decompression and fusion. The mean intraoperative blood loss in the overall population was 359 ml (range, minimum-2190 ml) and was 401 ml and 267 ml in the embolization (+) and embolization (-) groups, respectively. Four patients (9%) (2 patients from each group) required blood transfusion. There were no significant between-group differences in blood loss and blood transfusion requirements. All 7 patients with hypervascular tumors were in the embolization (+) group. Two patients experienced muscle weakness in the lower extremities on days 1 and 3 after embolization. There were metastases in T5 and T1-2, and magnetic resonance imaging after embolization showed slight exacerbation of spinal cord compression. The patients showed partial recovery after surgery. Conclusions: With the predominance of hypervascular tumors in the embolization (+) group, preoperative embolization may positively affect intraoperative bleeding. Embolization of metastatic spinal tumors may pose a risk of paralysis. Although the cause of paralysis remains unclear, it might be due to the aggravation of spinal cord compression. Considering this risk of paralysis, we advocate performing surgery as soon as possible after embolization.

Association between sagittal spinopelvic alignment and femoral head destruction in the early stage of rapidly destructive coxopathy.

AIMS: This study aimed to evaluate sagittal spinopelvic alignment (SSPA) in the early stage of rapidly destructive coxopathy (RDC) compared with hip osteoarthritis (HOA), and to identify risk factors of SSPA for destruction of the femoral head within 12 months after the disease onset. METHODS: This study enrolled 34 RDC patients with joint space narrowing > 2 mm within 12 months after the onset of hip pain and 25 HOA patients showing femoral head destruction. Sharp angle was measured for acetabular coverage evaluation. Femoral head collapse ratio was calculated for assessment of the extent of femoral head collapse by RDC. The following parameters of SSPA were evaluated using the whole spinopelvic radiograph: pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), sagittal vertical axis (SVA), thoracic kyphosis angle (TK), lumbar lordosis angle (LL), and PI-LL. RESULTS: The HOA group showed higher Sharp angles compared with the RDC group. PT and PI-LL were higher in the RDC group than the HOA group. SS and LL were lower in the RDC group than the HOA group. No difference was found in PI, SVA, or TK between the groups. Femoral head collapse ratio was associated with PT, SS, SVA, LL, and PI-LL. A PI-LL > 20° and a PT > 30° correlated with greater extent of femoral head destruction by RDC. From regression analysis, SS and SVA were significantly associated with the femoral head collapse ratio within 12 months after disease onset. CONCLUSION: Compared with HOA, RDC in the early stage correlated with sagittal spinopelvic malalignment. SS and SVA may partially contribute to the extent of femoral head destruction by RDC within 12 months after the onset of hip pain. The present study indicates a potential role of SSPA assessment in identification of RDC patients at risk for subsequent bone destruction. Cite this article: Bone Jt Open 2022;3(1):77-84.

Mortality related to and functional outcomes of upper cervical spine fractures in the elderly.

BACKGROUND: Although the mortality related to hip fracture and osteoporotic vertebral fracture have been reported, few studies have examined the mortality related to atlas and/or axis fractures. The aim of this study was to assess the association between mortality and atlas and/or axis fractures retrospectively and to elucidate the efficacy of surgical treatment. METHODS: A total of 33 elderly patients who were treated for atlas and/or axis fractures at our institution between January 2012 and December 2018 were included in this study. These patients were divided into two groups: surgical treatment and conservative treatment. Fracture types, comorbidities, neurological status, treatment types, and walking ability at follow-up were reviewed. Mortality was assessed using medical records or via phone interviews. RESULTS: The mean age at injury was 79.9 ± 8.0 years, and the mean follow-up period was 2.3 years. The overall mortality rates at 1 and 5 years were 21.4% and 48.4%, respectively. During the observation period, 12 (36%) patients died. Twenty-two patients were treated conservatively (14 were treated with a cervical collar, 8 were treated with a halo vest). Surgical procedures included occipital-cervical fixation, osteosynthesis of C2 fractures, C1-2 fixation, and C1-4 fixation using a posterior approach. Surgical treatment correlated with better survival rates. There was no significant difference between the two groups in terms of ambulatory ability and functional recovery. CONCLUSION: Upper cervical spine fractures appear to have a worse prognosis compared to hip and osteoporotic vertebral fractures. This study indicates the efficacy of surgical treatment for upper cervical spine fractures in the elderly for improving survival prognosis.

Bone turnover markers in the early stage of rapidly progressive osteoarthritis of the hip.

OBJECTIVE: Previous reports have demonstrated that patients with end-stage rapidly progressive osteoarthritis of the hip (RPOH) show significantly higher serum levels of bone turnover markers than those with osteoarthritis (OA). However, the characteristics of bone turnover markers in the early stage of RPOH remain unclear. This study aimed to elucidate the association of bone turnover markers with disease progression in the early stage of RPOH. METHODS: This study included 29 postmenopausal female patients with joint space narrowing >2 mm demonstrated on a series of radiographs and computed tomography within 1 year following the onset of hip pain. The study also included 9 postmenopausal female patients with hip OA secondary to developmental dysplasia showing femoral head destruction. Cortical thickness index (CTI) associated with bone mineral density of the hip was analyzed. Serum concentrations of tartrate-resistant acid phosphatase-5b (TRACP-5b) and bone alkaline phosphatase (BAP) were evaluated. RESULTS: RPOH was classified into two types on the basis of the absence (type 1, n=13) or presence (type 2, n=16) of subsequent destruction of the femoral head within 1 year following disease onset. TRACP-5b and BAP significantly increased in RPOH type 2 compared with type 1 and OA. Receiver operating characteristic curve analyses indicated that TRACP-5b and BAP could differentiate RPOH type 2 from type 1 within 1 year following the onset. CTI showed no difference among the RPOH types 1 and 2 and OA. CONCLUSION: High serum levels of bone turnover markers may be associated with destruction of the femoral head in the early stage of RPOH.

Characterization of rapidly progressive osteoarthritis of the hip in its early stage.

OBJECTIVE: This study aimed to characterize the process of disease progression in the early stage of rapidly progressive osteoarthritis of the hip (RPOH) and clarify its association with potential pathological factors of RPOH. METHODS: This monocentric retrospective study included 41 female patients who met the criteria for RPOH, chondrolysis >2 mm during 12 months from the onset of hip pain based on a series of radiographs and computed tomography. This study also included 9 female patients with osteoarthritis secondary to developmental dysplasia of the hip (DDH) who demonstrated chondrolysis >2 mm during 12 months from the onset of hip pain. Cortical thickness index (CTI) correlated with bone mineral density of the hip, pelvic tilt, and serum concentrations of matrix metalloproteinase (MMP)-3 were analyzed. RESULTS: RPOH was classified into two types based on the absence (type 1, n=17) and presence (type 2, n=24) of subsequent femoral head destruction within 12 months after the onset of hip pain. MMP-3 significantly increased in RPOH type 2 compared with type 1 and DDH. Increased posterior pelvic tilt was found in RPOH type 2 compared with DDH. Logistic regression and receiver operating characteristic curve analyses indicated that MMP-3 may be associated with differentiation between RPOH types 1 and 2. No difference was found in the CTI between the RPOH types and DDH. CONCLUSION: Disease progression of RPOH during 12 months after the onset of hip pain could be classified into two distinct types based on the absence (type 1) and presence (type 2) of femoral head destruction in association with MMP-3 and pelvic tilt as biological and mechanical factors, respectively. MMP-3 may be helpful to differentiate these two types in the early stage of RPOH.

Vertebroplasty Using Allograft Bone Chips with Posterior Instrumented Fusion in the Treatment of Osteoporotic Vertebral Fractures with Neurological Deficits.

INTRODUCTION: In general, osteoporotic vertebral fractures with neurological deficits require surgery. However, the ideal surgical method remains controversial. We evaluated the efficacy of combining posterior instrumented fusion and vertebroplasty using allograft bone chips. METHODS: Twelve patients (five men, seven women; age 68-84 years, mean age 75.9 years) with osteoporotic vertebral fractures with neurological deficits were reviewed retrospectively. They underwent posterior instrumented fusion and vertebroplasty, using allograft bone, at our institution between January 2007 and June 2016. We assessed the surgical results, radiologically and neurologically, after a mean follow-up of 37.3 months. RESULTS: The mean local kyphosis angle was 10° before surgery, -3.3° immediately after surgery, and 4.4° at follow-up. The average spinal canal compromise was 26.9% before surgery and 19.5% at follow-up. All patients achieved bony fusion and none needed additional surgery. All patients improved by at least one grade on the modified Frankel grading system. CONCLUSIONS: Combining vertebroplasty, using allograft bone chips, and posterior instrumented fusion appears to be an effective option for osteoporotic vertebral fractures with neurological deficits.