The residual exposed endplate ratio is predictive of posterior heterotopic ossification after cervical Bryan disc arthroplasty.

OBJECTIVES: Heterotopic ossification (HO), a major cause of dysfunction after disc arthroplasty (CDA). The aim of this study was to determine the cut value of the residual exposed endplate (REE) ratio and to predict the development of posterior HO after Bryan CDA. METHODS: This retrospective study investigated the relationship between the REE ratio and posterior HO formation after Bryan CDA. Consecutive adult patients who underwent 1- or 2-level Bryan CDA by a single neurosurgeon between 2006 and 2016 with at least two years follow-up were included. Postoperative radiographic analysis and measurement were performed to obtain the REE ratio and the HO grade. RESULTS: Of 249 patients with 384 surgical levels who underwent Bryan CDA during the study period, 114 (45.8 %) received 1-level CDA and 135 (54.2 %) received 2-level CDA. Lateral radiographs showed that 169 implants (44 %) had posterior HOs in all grades after two years or more of follow up and 14 implants (3.64 %) had severe HO (McAfee grades 3 and 4). In 329 implants (85.7 %), a comparison of radiographs to CT examination of HO grading showed a substantial relationship. Using area under the curve (AUC) analysis, a REE ratio >9 %, with 65.1 % sensitivity and 86.5 % specificity, was the cut point for posterior HO formation. CONCLUSIONS: REE is highly correlated with the development of postoperative posterior HO after Bryan CDA, regardless of the level of implantation. An undersized implant causing a REE ratio >9 % is a predictor of postoperative posterior HO formation after cervical Bryan CDA.

Radiological and clinical long-term results of heterotopic ossification following lumbar total disc replacement.

BACKGROUND: The long-term results of heterotopic ossification (HO) following lumbar total disc replacement (TDR) and the corresponding clinical and radiological outcomes are unclear. PURPOSE: This study aimed to report the long-term results of HO following lumbar TDR and to analyze the clinical and radiological outcomes. STUDY DESIGN/SETTING: A retrospective case review was performed for the consecutive patients who underwent lumbar TDR. PATIENT SAMPLE: The study included 48 patients (60 segments) who underwent lumbar TDR. OUTCOME MEASURES: The time and location of HO development, segmental range of motion (ROM) of index level, the visual analog scale (VAS), and the Oswestry Disability Index (ODI) were analyzed. METHODS: Forty-eight patients (60 segments) were divided into HO and non-HO groups, and radiographs were used to measure the time and location of HO development. We compared segmental ROM between two groups using flexion-extension radiographs. Clinical outcomes were assessed using the VAS and the ODI. Furthermore, the segmental ROM, VAS, and ODI scores of each HO class were compared with those of the non-HO group. RESULTS: The mean follow-up duration was 104.4 months. Heterotopic ossification was detected in 30 of 60 segments following lumbar TDR, and HO progression was noted in six segments. The mean segmental ROM was significantly lower in the HO group than in the non-HO group. The mean VAS and ODI scores were not significantly different between the two groups. Segmental ROM was significantly lower in the class III and IV of the HO group than in the non-HO group. The VAS and ODI scores were not significantly different among the different classes. CONCLUSIONS: We found that the incidence of HO is the highest within 12 months after lumbar TDR, and the incidence might increase 5 years after surgery. Furthermore, HO progressed over time. Segmental ROM was decreased in the HO groups; however, the limitation in motion might have little clinical influence.

Comparison of TLICS & McAfee Classification in Thoracolumbar Injuries

STUDY DESIGN: A retrospective study. OBJECTIVES: We assessed the intraobserver and interobserver reliability of TLICS classification in the thoracolumbar injuries, which had been evaluated in our hospital. It was compared with that of the older, McAfee classification and discussed for clinical validation. SUMMARY OF LITERATURE REVIEW: Among the numerous literatures regarding the thoracolumbar injury, there is no consensus on the most useful classification, and there is nothing comparing the McAfee classification with the TLICS classification. MATERIALS AND METHODS: Among the 230 patients that were treated with conservative care or operation from January 1, 2005 to January 1, 2010 in our hospital, 185 patients with initial CT and MRI images were assessed. Five orthopedic surgeons reviewed histories, plain film, CT and MRI of the 185 thoracolumbar injury cases, respectively. Each case was classified and scored according to the McAfee classification and the TLICS classification. The case assessment was recorded and the orthopedic surgeons repeated the assessment 1 month later. Intraobserver and interobserver reliability were assessed by statistical analysis. The actual management of each case was compared with the treatment recommended by TLICS classification to calculate the validity of the indexes. RESULTS: Intraobserver and interobserver reliability in TLICS were higher than those in the McAfee classification. Agreement of the TLICS classification for treatment recommendation was 81.7%, comparing with the actual management of previous McAfee classification. Validity indexes were satisfactory in therapeutic decision making, especially specificity. CONCLUSIONS: TLICS classification has a relative high K-value, when compared with that of the McAfee classification for intraobserver and interobserver reliability. Through clinical studies, including prospective observational analysis, TLICS classification can be applied and adjusted more adequately.

Measurement of Vertebral Compression and Kyphosis in the Thoracolumbar and Lumbar Fractures

STUDY DESIGN: A retrospective radiologic study. OBJECTIVES: We wanted to compare the compression ratio and kyphosis of thoracolumbar and lumbar fractures according to the radiologic measuring methods and we wanted to analyze their relationship with the stability of fracture. SUMMARY OF THE LITERATURE REVIEW: There are several methods for measuring the compression ratio and kyphotic angle in thoracolumbar fractures, but no definitive measurements and no different values according to the stability have been established. MATERIALS AND METHODS: From July 2002 to August 2008, the plain films, CT, MRI and medical records of thoracolumbar and lumbar fracture were reviewed. The compression ratio and kyphotic angle were calculated by several different formulas with using the lateral view of the plain X-ray film, the sagittal reconstruction image of CT and the sagittal image of MRI and the results were compared. Each subject was classified according to both McAfee's classification and the TLISS classification. RESULTS: Two hundred forty eight vertebral bodies of 205 thoracolumbar fracture patients were analyzed. The compression ratio according to formula 1, which was calculated as 1-anterior vertebral height/posterior vertebral height, was significantly correlated with Cobb's angle and the local kyphotic angle. There was no significant difference between the Cobb's angle calculated using the lateral X-ray and that using the sagittal view of CT; however, it was significantly less using the sagittal MRI view. The unstable fractures according to McAfee's classification showed a significantly higher compression ratio and kyphotic angle compared to those of the stable fractures. CONCLUSIONS: The compression ratio formula 1 was most significantly correlated with the kyphotic deformity. The unstable fractures showed a mean compression ratio higher than 30%, a mean Cobb's angle of 15degrees and local kyphotic angle of 18degrees. The sagittally reconstructed CT was a useful measuring method for the evaluation of kyphotic deformity, and it was more accurate than that of the plain film.

State v. McAfee.

KIE: Larry James McAfee, a quadriplegic incapable of breathing without a ventilator, petitioned the court seeking permission to turn off his ventilator. He further requested a sedative to alleviate the pain that would be caused by the cessation of oxygen. The trial court granted his petition, ruling that his right to refuse treatment outweighed the state's general interest in preserving life, and the state appealed. The Georgia Supreme Court affirmed the trial court's decision. The Supreme Court also ruled that McAfee's right to be free from pain was inseparable from his right to refuse treatment. McAfee's right to control his own treatment included the administration of a sedative when the ventilator was turned off. The Supreme Court declared that Georgia's living will legislation was irrelevant in this case, because McAfee was a competent adult and his condition was not terminal.^ieng