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  • SAGE Publications  (6)
  • Arnold, Paul  (6)
  • 1
    Online Resource
    Online Resource
    Cervical Spondylotic Myelopathy: Does Surgical Approach Influence Postoperative Sagittal Alignment and Outcomes?
    SAGE Publications ; 2015
    In:  Global Spine Journal Vol. 5, No. 1_suppl ( 2015-05), p. s-0035-1554529-s-0035-1554529
    Details
    In: Global Spine Journal, SAGE Publications, Vol. 5, No. 1_suppl ( 2015-05), p. s-0035-1554529-s-0035-1554529
    Abstract: The effect of surgical approach on outcomes for cervical spondylotic myelopathy (CSM) is controversial. Fehlings et al showed that patients treated with anterior techniques tend to be younger, less impaired, and had more focal pathology. In this study, we compared outcomes of an anterior approach group (AAG) versus a posterior approach group (PAG) with a focus on the effect of sagittal alignment. Patients and Methods Post hoc analysis of a prospective, multicenter database of patients with CSM. A total of 117 patients met inclusion criteria, were nonrandomized to an AAG ( n = 51) or PAG ( n = 62), with postoperative static lateral radiographs, Nurick assessment, and health-related quality of life outcomes at 6 months and/or 1 year. The AAG underwent anterior decompression and fusion, PAG either laminoplasty or laminectomy with fusion. Sagittal regional and focal parameters were compared by multivariate regression. Results At baseline, the groups showed significant age difference (AAG 51 years, PAG 62 years, p  〈  0.001), rheumatological comorbidity (AAG 3%, PAG 19%, p = 0.011), and modified Japanese orthopaedic association (mJOA). The PAG had significantly more regional malalignment at baseline, but there were no focal alignment differences between the two. Surgical features were significantly different for greater than three levels treated (AAG 27%, PAG 97%, p  〈  0.001) and blood loss (AAG 152 mL, PAG 380 mL, p  〈  0.001). After surgery, both AAG and PAG improved significantly in mJOA and Nurick grade, however, there was no statistically significant difference in mJOA postoperatively. AAG had a significant decrease in SVA whereas the PAG had a significant increase in SVA. There were no relevant postoperative focal alignment differences. Conclusion The PAG had older patients with more disability. Even when age, baseline mJOA, and regional parameters were controlled, the PAG cohort still correlated with worse CGH_C7 SVA and TS–CL. It is interesting to note that the PAG had a lower mJOA than the AAG at baseline, they both improved and were not significantly different postoperatively. This suggests that both techniques relieve symptomatic disease, but patients in the posterior group may continue to progress in sagittal misalignment.
    Type of Medium: Online Resource
    ISSN: 2192-5682 , 2192-5690
    URL: Article
    DOI: 10.1055/s-0035-1554529
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2015
    detail.hit.zdb_id: 2648287-3
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  • 2
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    Assessment of Impact of Long-Cassette Standing X-rays on Surgical Planning for Lumbar Pathology: An International Survey of Spine Surgeons
    SAGE Publications ; 2015
    In:  Global Spine Journal Vol. 5, No. 1_suppl ( 2015-05), p. s-0035-1554393-s-0035-1554393
    Details
    In: Global Spine Journal, SAGE Publications, Vol. 5, No. 1_suppl ( 2015-05), p. s-0035-1554393-s-0035-1554393
    Abstract: Surgical planning to address significant lumbar spine pathology, performed without appreciation of global spinal alignment, may have negative consequences. Our objective was to assess whether the extent of recommended surgery for lumbar pathology would significantly change with the addition of long-cassette standing X-rays. Materials and Methods This was an international online survey of spine surgeons. A series of 15 cases of lumbar spine pathology was presented with a brief clinical vignette and lumbar imaging (X-rays and MRI/CT). Surgeons were asked to select the most appropriate surgical plan, with five choices, ranging from least aggressive (decompression alone; 1 point) to the most aggressive (upper thoracic to sacrum/ilium fusion ± osteotomies/decompression/interbodies; 5 points). Cases were then reordered and presented with long-cassette standing X-rays and the same surgical planning question. Results were compared based on lumbar imaging only versus addition of long-cassette X-rays. Five cases (control group) had normal global alignment and 10 cases (study group) had global malalignment. Results A total of 316 surgeons completed the survey, predominantly (63%) from North America and Europe. Specialties included orthopedic surgery (65%) and neurosurgery (34%), 68% completed spine fellowship, and responders had a mean 13.4 years in practice that was a mean of 76% spine and included a mean of 123 fusions per year. For study cases, extent of recommended surgery increased significantly with the addition of long-cassette X-rays versus lumbar imaging only ( p = 0.002). For control cases with normal global alignment, no significant changes in surgery plans were identified with the addition of long-cassette X-rays ( p = 0.280). Conclusion Long-cassette standing X-rays can have a significant impact on surgical planning for lumbar pathology. Surgeons should maintain a relatively low threshold for obtaining long-cassette standing X-rays when contemplating surgical treatment for significant lumbar spine pathology.
    Type of Medium: Online Resource
    ISSN: 2192-5682 , 2192-5690
    URL: Article
    DOI: 10.1055/s-0035-1554393
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2015
    detail.hit.zdb_id: 2648287-3
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  • 3
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    Impact of Regional and Focal Cervical Alignment on Myelopathy Severity: Report of 151 Patients
    SAGE Publications ; 2015
    In:  Global Spine Journal Vol. 5, No. 1_suppl ( 2015-05), p. s-0035-1554134-s-0035-1554134
    Details
    In: Global Spine Journal, SAGE Publications, Vol. 5, No. 1_suppl ( 2015-05), p. s-0035-1554134-s-0035-1554134
    Abstract: Cervical sagittal alignment (C2–C7 SVA) has been correlated to myelopathy severity but kyphosis as a regional parameter has not been demonstrated to correlate with health-related quality of life (HRQOL) measures. We hypothesized that regional and focal sagittal cervical alignment may also correlate with HRQOLs in patients with cervical spondylotic myelopathy (CSM). Patients and Methods Post hoc analysis of a prospective, multicenter database of patients with CSM. A total of 151 patients met inclusion criteria (47%): symptomatic CSM, age  〉  18 years, baseline lateral radiographs, modified Japanese Orthopaedic Association (mJOA) and neck disability index (NDI). Average age was 56.3 ± 11.7 years with females making up 43.9% ( n = 69) of the study population. Regional alignment and HRQOLs were analyzed with patients stratified into a high-cSVA group (hiSVA, n = 45, 0.5 SD ≥ mean) or a low cSVA group (loSVA, n = 43, 0.5 SD ≤ mean). Focal alignment (kyphosis and olisthesis between adjacent vertebrae) analysis was also conducted. Results The hiSVA (mean cSVA 39.4 ± 7.4 mm) cohort had a significantly worse mJOA than the loSVA (mean cSVA 11.31 ± 5.3 mm) cohort (mean mJOA 12.5 vs. 13.7, p = 0.037). No significant correlations between C2–C7 lordosis and HRQOLs existed. There were significant correlations with focal alignment and worse clinical assessments: max sagittal slip with mJOA ( R = −0.24, p = 0.002) and Nurick ( R = 0.18, p = 0.024). Level of slip was also significant, with olisthesis at higher levels correlating with worse health status. Number of kyphotic segments also positively correlated with NDI ( R = 0.19, p  〈  0.001). Conclusion Similar to previous studies, high baseline cSVA correlated with significantly worse mJOA. Interestingly, the mean cSVA of the hiSVA cohort was 39.4 ± 7.4 mm, suggesting that 40 mm may be a potential threshold below which cervical sagittal malalignment should be corrected. Regarding focal alignment, increased olisthesis is correlated with worse mJOA and Nurick grade, especially at higher cervical levels. Even focal abnormalities all along the cervical spine are correlated with worse NDI, demonstrating that while level of olisthesis may matter, the number of vertebrae with a kyphotic relationship may also cause pain and disability.
    Type of Medium: Online Resource
    ISSN: 2192-5682 , 2192-5690
    URL: Article
    DOI: 10.1055/s-0035-1554134
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2015
    detail.hit.zdb_id: 2648287-3
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  • 4
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    Online Resource
    Area under the Curve: Analysis of Approach-Related Recovery Time in 165 Operative Cervical Spondylotic Myelopathy Patients with a 2-Year Follow-Up
    SAGE Publications ; 2015
    In:  Global Spine Journal Vol. 5, No. 1_suppl ( 2015-05), p. s-0035-1554527-s-0035-1554527
    Details
    In: Global Spine Journal, SAGE Publications, Vol. 5, No. 1_suppl ( 2015-05), p. s-0035-1554527-s-0035-1554527
    Abstract: Much debate about postoperative outcomes regarding surgical approaches for cervical spondylotic myelopathy (CSM) exists in the literature with no clear evidence of superiority. We propose a novel method for assessing health-related quality of life (HRQOL) outcomes by taking into account each patient's baseline at postoperative time points and analyzing the “area under the curve” (AUC), a proxy for suffering time. Patients and Methods Post hoc analysis of a prospective, multicenter database of patients with CSM. A total of 165 patients met the following inclusion criteria: symptomatic CSM, age older than 18 years, and 2-year follow-up with modified Japanese Orthopaedic Association (mJOA) and neck disability index (NDI). The anterior approach group (AAG) ( n = 110) and posterior approach group (PAG) ( n = 55) were compared at baseline, 1 year, and 2 years for each HRQOL. This comparison was repeated with normalization, using the patient's baseline as the anchor, followed by an integration and comparison of AUC. Results and Conclusion: For the first time, AUC analysis was applied to evaluating patients with CSM. Nonnormalized HRQOLs demonstrated the AAG started higher and met better standards at all times points compared with the PAG. Normalized mJOA demonstrated the PAG actually did better at 2 years, whereas NDI suggested that the AAG did better, although this was not significant. AUC analysis further supported the superiority of the PAG, with statistical significance at 1 and 2 years' time points, suggesting that patients who undergo the posterior approach may suffer less in the first 2 years of their postoperative course.
    Type of Medium: Online Resource
    ISSN: 2192-5682 , 2192-5690
    URL: Article
    DOI: 10.1055/s-0035-1554527
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2015
    detail.hit.zdb_id: 2648287-3
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  • 5
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    The Impact of Dynamic Alignment, Motion, and Center of Rotation on Myelopathy Grade and Regional Disability in Cervical Spondylotic Myelopathy
    SAGE Publications ; 2015
    In:  Global Spine Journal Vol. 5, No. 1_suppl ( 2015-05), p. s-0035-1554137-s-0035-1554137
    Details
    In: Global Spine Journal, SAGE Publications, Vol. 5, No. 1_suppl ( 2015-05), p. s-0035-1554137-s-0035-1554137
    Abstract: Cervical stenosis is a defining feature of CSM. Matsunaga et al proposed that elements of stenosis are both static and dynamic, where the dynamic elements magnify the canal deformation of the static state. We hypothesize that dynamic motion may be associated with myelopathy severity and neck disability and present novel methods of dynamic motion analysis in CSM. Patients and Methods Post hoc analysis of a prospective, multicenter database of patients with CSM. A total of 110 patients (34%) met inclusion criteria symptomatic CSM, age over 18 years, baseline flexion/extension radiographs, and HRQOLs (mJOA, NDI, SF-36, and Nurick grade). The mean age was 57 ± 12 years with 41% female ( n = 46). Correlations with HRQOLs were analyzed for regional and focal parameters in flexion and extension. Baseline dynamic parameters (F/E cone relative to a fixed C7, center of rotation, range of motion arc relative to the COR) were also analyzed for correlations to HRQOLs. Results At baseline, the mean HRQOLs demonstrated disability and the mean radiographic parameters demonstrated sagittal malalignment. Among regional parameters, there was a significant correlation between increased C2–C7 angle in flexion and Nurick grade ( R = 0.189, p = 0.048) with no significant correlations in extension. Focal parameters including C7 slip were significantly correlated with disability (Flex R = −0.377, p = 0.003; Ext R = −0.261, p = 0.027). Reduced flexion/extension motion cones, a more posterior center of rotation, and smaller range of motion correlated with worse HRQOLs. Conclusion Dynamic motion analysis may play an important role in understanding CSM. Focal parameters demonstrated a significant correlation with worse HRQOLs especially C7 slip in flexion and extension. Novel methods of motion analysis demonstrated reduced motion cones correlated with worse myelopathy grades. More posterior center of rotation and smaller range of motion were both correlated with worse general health scores (PCS and Nurick).
    Type of Medium: Online Resource
    ISSN: 2192-5682 , 2192-5690
    URL: Article
    DOI: 10.1055/s-0035-1554137
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2015
    detail.hit.zdb_id: 2648287-3
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  • 6
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    Correlation of Myelopathy to Regional Neck Disability: A Surgical Approach-Specific Analysis in 217 Patients
    SAGE Publications ; 2015
    In:  Global Spine Journal Vol. 5, No. 1_suppl ( 2015-05), p. s-0035-1554528-s-0035-1554528
    Details
    In: Global Spine Journal, SAGE Publications, Vol. 5, No. 1_suppl ( 2015-05), p. s-0035-1554528-s-0035-1554528
    Abstract: Outcomes for cervical spondylotic myelopathy (CSM) have been measured by numerous health-related quality of life (HRQOL) scales such as the disease-specific modified Japanese Orthopaedic Association (mJOA) and the regional-specific neck disability index (NDI). However, there is no literature analyzing the correlation of myelopathy improvement to regional neck disability changes after surgery. Materials and Methods Post hoc analysis of a prospective, multicenter database of patients with CSM. A total of 217 patients (78%) met the following inclusion criteria: symptomatic CSM, age over 18 years, and 6 months follow-up with mJOA and NDI. The patient population had a mean age of 57 years and 42% were females ( n = 92). NDI and mJOA were analyzed at baseline and 6 months post-op for the entire group. Correlations were also analyzed by the following subgroups: anterior approach group (AAG, n = 141) and posterior approach group (PAG, n = 76). Results From baseline to 6 months, there was a statistically significant improvement in both mJOA (BL 12.87–6 M 15.25, p  〈  0.0001) and NDI (BL 42.25–6M 31.61, p  〈  0.0001) in the overall group. There was a significant small negative correlation between NDI and mJOA at baseline ( R =  − 0.34, p  〈  0.0001) and at 6-month follow-up ( R =  − 0.44, p  〈  0.0001). Within the AAG, there was also a significant negative correlation between NDI and mJOA at baseline ( R =  − 0.31, p  〈  0.0001) and 6 months ( R =  − 0.53, p  〈  0.0001). Within the PAG, there was also a significant negative correlation between NDI and mJOA at baseline ( R =  − 0.43, p  〈  0.0001) and 6 months ( R =  − 0.34, p = 0.003). Conclusion Overall, NDI has a significant negative correlation with mJOA at baseline and postoperatively in patients with CSM. This correlation increases postoperatively in the overall group. The PAG showed a decrease in the correlation coefficient after surgery, whereas the AAG showed an increase. This could be because the posterior approach tended to be a more extensive surgery for multilevel disease in older patients, compared with the anterior approach, resulting in more soft tissue disruption and a delay in neck active motion. Regardless of the approach, mJOA still remains significantly correlated with NDI.
    Type of Medium: Online Resource
    ISSN: 2192-5682 , 2192-5690
    URL: Article
    DOI: 10.1055/s-0035-1554528
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2015
    detail.hit.zdb_id: 2648287-3
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