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Background: Pedicle screw and rod instrumentation based on titanium can produce satisfying strength and stiffness for spinal fusion. However, excessive stiffness produced by titanium rods may cause stress shielding. Thus, polyetheretherketone (PEEK) rods with a low modulus of elasticity were introduced as substitutes for titanium rods. The purpose of this paper is to compare the effectiveness of PEEK rods versus titanium alloy rods in anterior spinal fusion with a new sheep model.Methods: Sheep models of anterior-posterior cervical fusion were innovatively adopted in our study. Twenty-four sheep were randomly divided into a control group and a treatment group that received anterior-posterior cervical fixation with titanium rods or PEEK rods, respectively. Then, surgical segments were harvested and assessed by X-ray, micro-CT and histological examination to evaluate the efficiency of bone fusion.Results: No complications related to fixation were found during the research process. The results of the X-ray showed a stronger spinal fusion in the PEEK rod groups than in the titanium rod group at 12 weeks postoperatively, and both groups underwent bone fusion at 24 weeks postoperatively. The results of micro-CT showed that fixation with PEEK rods achieved better bone ingrowth at an early postoperative stage (12 weeks) compared to fixation with titanium rods (bone volume fraction (BVF): 20.26 ± 4.36% vs 14.48 ± 3.49%, p < 0.05). The same trend was detected in the histological analysis, where the mineralized bone fraction in the experiment group (21.01 ± 3.48%) was significantly higher than that in the control group (16.73 ± 2.95%). In addition, better osseointegration was found in the experiment group at the early postoperative stage at 12 weeks (bone apposition (BA): 16.22 ± 3.24% vs 11.67 ± 3.63%, p < 0.05). However, there were no significant differences at 24 weeks postoperatively.Conclusion: PEEK rods can be used safely in a sheep model of anterior-posterior cervical fixation. Compared to traditional titanium rods, earlier and more evident bone fusion was found in the PEEK rods group. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Introduction: Since its introduction BMP has been utilized in populations with higher rates of malunion, such as adult spinal deformity (ASD) patients. Contradictory conclusions exist in spinal literature regarding the safety and efficacy of the use of BMP in this setting. Previous studies, however, did not distinguish deformity cases from spondylolisthesis or stenosis. The purpose of this study is to evaluate the safety and efficacy of BMP use in spinal fusion surgery for ASD.Methods: 166 papers were screened after database search. 40 full texts were assessed for eligibility. Five studies were included for meta-analysis. Three were comparative studies between a BMP and non-BMP group, and the other was used to supplement dose-effect analysis.Results: The current meta-analysis found increased odds of developing radiculitis or neurological complications (OR = 2.18, 95% CI, p = 0.02, i 2 = 0), but no other significant relationship between complications commonly attributed to BMP use (tumorigenesis, infections, seroma formation, or osteolysis) and BMP use. BMP patients had decreased rates of pseudarthrosis (OR = 0.23, 95% CI, p = 0.002, i 2 = 0). There was an average dose of 8.75 mg/level in the 417 patients studied, lower than the advised dosage of 12 mg/level.Conclusions: The current literature shows BMP to be a safe and effective grafting technique in the treatment of ASD. Spine surgeons may currently be using sub-optimal doses of BMP. The benefit of increasing the rate of fusion must be weighed against the increased risk of radiculitis and neurologic complications in this patient population. [ABSTRACT FROM AUTHOR]

New noninvasive techniques, amongst them structured light methods, have been applied to study rachis deformities, providing a way to evaluate external back deformities in the three planes of space. These methods are aimed at reducing the number of radiographic examinations necessary to diagnose and follow-up patients with scoliosis. By projecting a grid over the patient's back, the corresponding software for image treatment provides a topography of the back in a color or gray scale. Visual inspection of back topographic images using this method immediately provides information about back deformity, but it is important to determine quantifier variables of the deformity to establish diagnostic criteria. In this paper, two topographic variables [deformity in the axial plane index (DAPI) and posterior trunk symmetry index (POTSI)] that quantify deformity in two different planes are analyzed. Although other authors have reported the POTSI variable, the DAPI variable proposed in this paper is innovative. The upper normality limit of these variables in a nonpathological group was determined. These two variables have different and complementary diagnostic characteristics, therefore we devised a combined diagnostic criterion: cases with normal DAPI and POTSI (DAPI < or = 3.9% and POTSI < or = 27.5%) were diagnosed as nonpathologic, but cases with high DAPI or POTSI were diagnosed as pathologic. When we used this criterion to analyze all the cases in the sample (56 nonpathologic and 30 with idiopathic scoliosis), we obtained 76.6% sensitivity, 91% specificity, and a positive predictive value of 82%. The interobserver, intraobserver, and interassay variability were studied by determining the variation coefficient. There was good correlation between topographic variables (DAPI and POTSI) and clinical variables (Cobb's angle and vertebral rotation angle). [ABSTRACT FROM AUTHOR]

[2019] 28:1821-1828) We read with interest the systematic review by Ricciardi et al. [[1]] on the effect of non-rigid cervical collar (nRCC) in the rehabilitation of whiplash injury. 10.1136/bmj.292.6521.656 8 Borchgrevink GE, Kaasa A, McDonagh D, Stiles TC, Haraldseth O, Lereim I. Acute treatment of whiplash neck sprain injuries. [Extracted from the article]

Purpose: We report a single-center, prospective, randomized study for pedicle screw insertion in opened and percutaneous spine surgeries, using a computer-assisted surgery (CAS) technique with three-dimensional (3D) intra-operative images intensifier (without planification on pre-operative CT scan) vs conventional surgical procedure.Material and Method: We included 143 patients: Group C (conventional, 72 patients) and Group N (3D Fluoronavigation, 71 patients). We measured the pedicle screw running time, and surgeon's radiation exposure. All pedicle runs were assessed according to Heary by two independent radiologists on a post-operative CT scan.Results: 3D Fluoronavigation appeared less accurate in percutaneous procedures (24 % of misplaced pedicle screws vs 5 % in Group C) (p = 0.007), but more accurate in opened surgeries (5 % of misplaced pedicle screws vs 17 % in Group C) (p = 0.025). For one vertebra, the average surgical running time reached 8 min in Group C vs 21 min in Group N for percutaneous surgeries (p = 3.42 × 10(-9)), 7.33 min in Group C vs 16.33 min in Group N (p = 2.88 × 10(-7)) for opened surgeries. The 3D navigation device delivered less radiation in percutaneous procedures [0.6 vs 1.62 mSv in Group C (p = 2.45 × 10(-9))]. For opened surgeries, it was twice higher in Group N with 0.21 vs 0.1 mSv in Group C (p = 0.022).Conclusion: The rate of misplaced pedicle screws with conventional techniques was nearly the same as most papers and a little bit higher with CAS. Surgical running time and radiation exposure were consistent with many studies. Our work hypothesis is partially confirmed, depending on the type of surgery (opened or closed procedure). [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to validate the Oswestry Spinal Risk Index (OSRI) in an external population. The OSRI predicts survival in patients with metastatic spinal cord compression (MSCC).Methods: We analysed the data of 100 patients undergoing surgical intervention for MSCC at a tertiary spinal unit and recorded the primary tumour pathology and Karnofsky performance status to calculate the OSRI. Logistic regression models and survival plots were applied to the data in accordance with the original paper.Results: Lower OSRI scores predicted longer survival. The OSRI score predicted survival accurately in 74% of cases (p = 0.004).Conclusions: Our study has found that the OSRI is a significant predictor of survival at levels similar to those of the original authors and is a useful and simple tool in aiding complex decision making in patients presenting with MSCC. [ABSTRACT FROM AUTHOR]

Purpose: Surgery of adult scoliosis was based upon coronal plane radiographical analysis using Cobb angle measurements, but recently it has been demonstrated that sagittal spinopelvic alignment plays a critical role in determining the final outcome. The aim of this paper is to compare the clinical and radiological results of 81 patients affected by adult scoliosis, treated with short or long fusions, and followed for 2-5 year follow-up.Materials and Methods: 81 patients affected by degenerative lumbar scoliosis managed by posterior-only surgery were retrospectively evaluated. Fifty-seven patients underwent to a short fusion procedure, while 24 had a long fusion. Clinical and radiographic coronal and sagittal spinopelvic parameters were compared between the two groups.Results: Coronal Cobb angle was 24° preoperatively and passed to 12° in the short fusion group, while changed from 45° to 10° in the long fusion group. Lumbar lordosis was 45° preoperatively and 60° at final follow-up in the short fusion group passed from 24° to 55° in the long fusion group. Sacral slope passed from 25° to 45° in the short fusion group, while from 10° to 40° in the long fusion group. Pelvic tilt passed from 24° to 13° in the short fusion group, and from 28° to 23° in the long fusion group.Conclusion: Surgical treatment of degenerative lumbar scoliosis improved balance and alignment of the spine, and also the coronal plane in terms of Cobb angle. These results were associated to a consistent clinical improvement and an acceptable rate of complications. [ABSTRACT FROM AUTHOR]

Introduction: Sacral chordoma is a rare low-to-intermediate grade malignant tumour. The mainstay of treatment is still surgery with en bloc and wide resection margins, which can grant the best chances of a long-term control or cure of this disease. The first aim of this paper is to collect data about survival, time to local recurrence and metastasis among patients affected by sacral chordoma and primarily treated with surgery. The second aim is to analyze the influence of level resection, tumor volume and surgical margins on local recurrence.Materials and Methods: The study population was composed of 14 patients treated with sacral chordoma resection at the National Tumour Institute of Naples-Pascale (Italy) from January 2000 to June 2013. The median follow-up was 84 months (range 24-132 months). The follow-up was characterized by: standard radiographs, MRI, and a CT scan of the chest annually. Time to recurrence or metastasis was calculated from the date of resection to the date of diagnosis of first recurrence or metastasis.Results: Out of all the patients, six died (42.86 %) during the follow-up; 6 (42.86 %) had local recurrence; 4 (28.57 %) had metastasis. At univariate analysis wide surgical margins (R0) were associated with increased survival up to a local recurrence (OR = 0.0286; 95 % CI = 0.0014-0.5739; P = 0.026); the level of resection (OR = 3.33; 95 % CI = 0.3619-30.7025; P = 0.592) and tumour volume (P = 1) did not show a statistically significant correlation.Discussion: Based on our experience, we hope all patients to be treated by surgery, the only good standard treatment of this disease. The resection should result in margins as wide as possible. For these reasons, it is essential for this disease to be treated in highly specialized centres because only a complete surgery can offer a chance to care for these patients.Conclusions: Solid survival at long-term follow-up can be achieved by a surgical resection performed with wide margins. [ABSTRACT FROM AUTHOR]

Purpose: This paper is to evaluate the efficacy and safety of transforaminal lumbar interbody fusion (TLIF) using unilateral pedicle screws along with contralateral translaminar facet joint screw (UPS+TFS) fixation in comparison with the method using bilateral pedicle screws fixation (BPS) in degenerative lumbar diseases.Methods: Forty patients with single-level lumbar diseases were divided into two groups randomly. One group was treated by TLIF with BPS fixation while the other group was treated by the new technique with UPS+TFS fixation. The preoperative and postoperative ODI, JOA, VAPS scores, mean operation time, mean operation blood loss, fusion rate and complications were collected for comparison under two surgical methods. In terms of complications, only two cases of superficial infection in the BPS group and one case of urinary tract infection in the other group was found.Results: The mean operation time and blood loss was significantly less in UPS+TFS group than in BPS group. The preoperation and postoperative ODI, JOA and VAPS at the intervals of 6 weeks, 3, 6 months and 1 year between the BPS and UPS+TFS group showed no significant disparities. Only one patient in UPS+TFS group was not fused with pseudoarthrosis formation.Conclusions: The clinical efficacy and safety of TLIF with UPS+TFS fixation were comparable to BPS fixation; however, the soft tissue injury and the corresponding operation cost were reduced with unilateral pedicle screw plus translaminar facet screw fixation. [ABSTRACT FROM AUTHOR]

Surgical instrumentation planning for the correction of scoliosis involves many difficult decisions, especially with the introduction of multi-segmental and other instrumentation technologies. A preliminary study has shown a high variability in planning among a small group of surgeons. The purpose of this paper was to evaluate and analyze the selection of fusion levels and instrumentation choices among a more extended group of scoliosis surgeons. Thirty-two experienced spinal deformity surgeons were asked to provide their preferred posterior instrumentation planning for five patients with adolescent idiopathic scoliosis (AIS) using a graphical worksheet and the usual preoperative X-rays. Overall, the number of implants used ranged from 8 to 30 per patient (mean 16; SD 6): 71% of these were mono-axial screws, 20% multi-axial screws, and 9% hooks. The selected superior and inferior instrumented vertebrae varied up to six levels. The following significant groups of strategies were identified: A- "All Pedicle Screws Constructs" [N(A) = 103; 66%]; B- "All Hooks constructs" [N(B) = 5; 3%]; C- "Hybrid Constructs" [N(C) = 48; 31%]. A top-to-bottom attachment sequence was selected in 49% of all cases, a bottom-up in 46%, and an alternate order in 4%. A large variability in preoperative instrumentation strategy exists in AIS within an experienced group of orthopedic spine surgeons. The impact of such choices on the resulting correction is questioned and will need to be determined with adequate clinical, biomechanical, and computer simulation prospective studies. [ABSTRACT FROM AUTHOR]

The classification presented in this paper is the first specifically designed to guide surgical treatment of L5-S1 spondylolisthesis in children and adolescents. It also presents objective criteria to differentiate between low- and high-dysplastic spondylolisthesis and incorporates recent knowledge in the study of sagittal spinopelvic balance. The proposed classification is based on the following: (1) the degree of slip, (2) the degree of dysplasia, and (3) the sagittal spinopelvic balance. To classify a patient, the degree of slip is quantified first to determine if it is low-grade, high-grade, or a spondyloptosis. Then, the degree of dysplasia is evaluated based on seven criteria, in order to separate patients with low- and high-dysplastic spondylolisthesis. Finally, the sagittal spinopelvic balance is assessed from the measurement of the pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT). For low-grade spondylolisthesis, it is classified as low PI/low SS (nutcracker type) or high PI/high SS (shear type). For high-grade spondylolisthesis, it is classified as high SS/low PT (balanced pelvis) or low SS/high PT (retroverted pelvis). Such a comprehensive classification could allow to better evaluate and compare available surgical techniques, and to optimize the treatment of L5-S1 spondylolisthesis. Because the classification was designed so that groups are organized in an ascending order of severity, it becomes easier and more intuitive to develop an associated surgical algorithm because the complexity of the surgery should increase as the severity of the spondylolisthesis increases. A tentative treatment algorithm is proposed but it is not definitive because further studies are required to define the most appropriate treatment for each group. [ABSTRACT FROM AUTHOR]

The results of lumbar fusion in chronic low back pain (LBP) patients vary considerably, and there is a need for proper patient selection. Lumbosacral orthoses have been widely used to predict outcome, however, with little scientific support. The aim of the present study was to determine the value of a pantaloon cast test in selecting chronic LBP patients for lumbar fusion or conservative management. First, a systematic review of the literature was carried out in which two independent reviewers identified studies in Medline, Cochrane and Current Contents databases. Three papers met the selection criteria. In the only study with a control group, a significantly better outcome after fusion compared to conservative treatment was found in patients who reported significant pain relief while in a cast (i.e. a positive cast test). The results of lumbar fusion, however, were not significantly different for patients with a positive and those with a negative cast test. In addition to the review, a clinical cohort study of 257 LBP patients, who had been allocated to either lumbar fusion or conservative management by a temporary external transpedicular fixation trial, was performed. Prior to allocation, all had undergone a pantaloon cast test. Patients with no history of prior spine surgery and with a positive pantaloon cast test had a better outcome after lumbar fusion than those treated conservatively (P = 0.002, chi (2 )test). In patients with previous spine operations the outcomes were poor and the test was of no value. From the literature and the present patient cohort, it was concluded that only in chronic LBP patients without prior spine surgery, a pantaloon cast test with substantial pain relief suggests a favorable outcome of lumbar fusion compared to conservative management. The test has no value in patients who have had previous spine surgery. [ABSTRACT FROM AUTHOR]

We performed a metaanalysis of one- and two-level anterior cervical interbody fusion (ACDF) on data derived from published, peer-reviewed journal articles to determine whether there is a difference in fusion rate, graft complications, or clinical outcome in patients undergoing ACDF according to whether autograft or allograft was used. ACDF is a common procedure for cervical spondylotic radiculopathy. Most published studies comparing autograft and allograft have not demonstrated any difference between grafts. The medical literature dating from 1955 was reviewed. Of 395 titles, only four studies comparing autograft with allograft in ACDF were appropriate for this analysis. The data from these studies--310 patients and 379 intervertebral levels were pooled and statistical methods were applied. For both one- and two-level ACDF, autograft demonstrated a higher rate of radiographic union and a lower incidence of graft collapse. It was not possible to ascertain whether autograft is clinically superior to allograft. Although autograft has a higher fusion rate than allograft, clinical results do not depend solely on radiographic results. The risk of graft site morbidity and patient preference should be considered when choosing the type of graft for this operation. [ABSTRACT FROM AUTHOR]

Idiopathic scoliosis involves complex spinal intrinsic deformations such as the wedging of vertebral bodies (VB) and intervertebral disks (ID), and it is obvious that the clinical evaluation obtained by the spinal projections on the two-dimensional (2D) radiographic planes do not give a full and accurate interpretation of scoliotic deformities. This paper presents a method that allows reconstruction in 3D of the vertebral body endplates and measurement of the 3D wedging angles. This approach was also used to verify whether 2D radiographic measurements could lead to a biased evaluation of scoliotic spine wedging. The 3D reconstruction of VB contours was done using calibrated biplanar X-rays and an iterative projection computer procedure that fits 3D oriented ellipses of adequate diameters onto the 3D endplate contours. “3D wedging angles” of the VB and ID (representing the maximum angle between adjacent vertebrae) as well as their angular locations with respect to the vertebral frontal planes were computed by finding the positions of the shortest and longest distances between consecutive endplates along their contour. This method was extensively validated using several approaches: (1) by comparing the 3D reconstructed endplates of a cadaveric functional unit (T8-T9) with precise 3D measurements obtained using a coordinate measuring machine for 11 different combinations of vertebral angular positions; (2) by a sensitivity study on 400 different vertebral segments mathematically generated, with errors randomly introduced on the digitized points (standard deviations of 0.5, 1, 2, and 3 mm); (3) by comparing the clinical wedging measurements (on postero-anterior and lateral radiographs) at the thoracic apical level of 34 scoliotic patients (15° < Cobb < 45°) to the computed values. Mean errors for the 11 vertebral positions were 0.5 ± 0.4 mm for VB thickness, less than 2.2° for endplate orientation, and about 11° (3 mm) for the location of the maximum 3D wedging angle along the endplate contour. The errors below 2 mm (introduced on the digitized points) slightly affected the 3D wedging angle (< 2°) and its location (< 4°) for the ID. As for the clinical evaluation, average angular errors were less than 0.4° in the radiographic frontal and lateral planes. The mean 3D wedged angles were about 4.9°± 1.9° for the VB and 6.0°± 1.7° for the ID. Linear relations were found between the 2D and the 3D angles, but the 3D angles were located on diagonal planes statistically different than the radiographic ones (between 100° and 221°). There was no statistical relation between the 2D radiographic angles and the locations of the 3D intervertebral wedging angles. These results clearly indicate that VB and ID endplates are wedged in 3D, and that measurements on plain radiographs allow incomplete evaluation of spinal wedging. Clinicians should be aware of these limitations while using wedging measurements from plain radiographs for diagnosis and/or research on scoliotic deformities. [ABSTRACT FROM AUTHOR]

Unexpected loads, which often occur in the working environment, can lead to high forces in the spine and, thus, may be a cause of low back injury. This paper discusses the effect of "sudden load" on the erector spine reaction and amplitude. Muscle responses were mediated by several factors, including fatigue, posture, expectation and rehabilitation, in chronic low back pain patients. The subjects were fatigued by holding a 20% maximum voluntary contraction for 1 min. A functional restoration program was tested for its efficacy in reducing reaction time and EMG amplitude in chronic low back pain patients. Reaction time was longer and EMG amplitude lower in patients than in their matched controls. EMG reaction time and magnitude decreased in patients after a 2-week rehabilitation program, including specific training of coordination and posture control. The results of the modelling showed higher spinal compressive load and lower shear forces when the load was expected than when the load was unexpected. The effect of sudden loads can be exacerbated if a worker is not standing on a flat surface or is fatigued. Chronic low back pain patients have less ability to protect themselves from sudden loads, but they can be trained to improve their response by means of an appropriate rehabilitation program. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this retrospective study is to evaluate the efficacy and safety of posterior-only vertebral column resection (PVCR) for the treatment of angular and isolated congenital kyphosis.Methods: 24 patients with isolated angular congenital kyphosis treated by PVCR in our hospital were retrospectively studied. The patients' radiographs and hospital records were reviewed. Deformity in sagittal planes and global sagittal alignment were analyzed for correction and maintenance of the correction in preoperative, postoperative, and follow-up radiographs. The complications and related risk factors were analyzed.Results: The average age was 13.9 (4-40) years. Three of them were revision surgeries. Two patients have intraspinal anomalies. The mean follow-up is 56.9 (26-129) months. The mean operation time was 293.1 (170-480) min. The averaged blood loss was 993.8 (250-3000) ml. The segmental kyphosis was 87.3° before surgery, 17.6° post surgery and 20.4° at the latest the follow-up. And the sagittal vertical axis was improved from 43.1 mm to 9.2 mm. Mean total score of SRS-22 was 89.3. Complications occurred in 4 patients, including 1 screw pullout due to pseudarthrosis, 1 proximal junctional kyphosis, 1 incomplete spinal cord injury and 1 root injuries.Conclusion: Posterior-only vertebral column resection is an ideal procedure for severe rigid congenital kyphosis. However, it is still a highly technical demanding procedure. Neurological compromises still remain the biggest challenges. Sufficient height of anterior reconstruction, avoidance sacrifice of bilateral roots in the same level in the thoracic spine, avoidance of the sagittal translation of the upper and lower vertebras, intra-operative neuromonitoring, and preoperative surgical release of diastematomyelia and tethered cord may help to improve the safety. [ABSTRACT FROM AUTHOR]

Purpose: To investigate potential associations between preoperative MRI findings and patient reported outcome measures (PROMs) after surgery for lumbar spinal stenosis (LSS).Methods: The NORDSTEN trial included 437 patients. We investigated the association between preoperative MRI findings such as morphological grade of stenosis (Schizas grade), quantitative grade of stenosis (dural sac cross-sectional area), disc degeneration (Pfirrmann score), facet joint tropism and fatty infiltration of the multifidus muscle, and improvement in patient reported outcome measures (PROMs) 2 years after surgery. We dichotomized each radiological parameter into a moderate or severe category. PROMs i.e., Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ) and Numeric rating scale (NRS) for back and leg pain were collected before surgery and at 2 year follow-up. In the primary analysis, we investigated the association between MRI findings and ODI score (dichotomized to ≥ 30% improvement or not). In the secondary analysis, we investigated the association between MRI findings and the mean improvement on the ODI-, ZCQ- and NRS scores. We used multivariable regression models adjusted for patients' gender, age, smoking status and BMI.Results: The primary analysis showed that severe disc degeneration (Pfirrmann score 4-5) was significantly associated with less chance of achieving a 30% improvement on the ODI score (OR 0.54, 95% CI 0.34, 0.88). In the secondary analysis, we detected no clinical relevant associations.Conclusion: Severe disc degeneration preoperatively suggest lesser chance of achieving 30% improvement in ODI score after surgery for LSS. Other preoperative MRI findings were not associated with patient reported outcome. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate an X-ray films analysis software, i.e. to estimate the reliability and validity of clinical measurements by means of this software. The authors first performed tests of precision and reproducibility of measures. The precision for dynamic modules was estimated at +/-2 degrees for the lumbar analysis and +/-3 degrees for the cervical one. Mean reproducibility coefficients calculated for postural modules are about 4 degrees for the angular parameters and 3 mm for the linear ones. We also evaluated clinical applicability of the software through its validity. Reference values calculated on a population of healthy subjects showed agreement with the literature. Then, when analysing postural X-ray films of severe scoliotic patients, we found that inter-observer reproducibility coefficients show a lower reliability of measurements; the main cause seems to be the low visibility of anatomic landmarks due to the quality of X-ray films and to the degree of deformity. This study allowed to better estimate the reliability and the usefulness of this tool, allowing for multicentric studies and exchanges. [ABSTRACT FROM AUTHOR]

Purpose: For adult spinal deformity (ASD) patients receiving operative (op) and non-operative (non-op) treatment, the relationship between HRQoL measures, complications and self-reported satisfaction remains unclear. The objective of this analysis is to study nonlinear association dynamics between ASD patient satisfaction, HRQoL, and complications over a two-year follow-up period.Methods: From a prospective multicenter international adult spinal deformity database, all patients with 2-year follow-up data on satisfaction (21st question of SRS-22r) were identified and included. A total of 12 LOESS (local polynomial fit) regressions were performed between patient satisfaction (SRS22 item 21) and HRQoL measures (ODI, SF36PCS and SRS22 subtotal) interacting with surgery at baseline, 6 months and 1 and 2 years of follow-up.Results: A total of 856 patients (527 op and 329 non-op) were included. At baseline, satisfaction was lower for patients scheduled for surgery even when HRQL was similar to those elected for conservative treatment. The nonlinear correlations showed that for similar PROMs, op patients reached higher satisfaction levels during follow-up, especially at six months. In fact, at six months operated patients with a deterioration of their initial PROMs had some improvement in their satisfaction, which could not be further observed at the end of follow-up.Conclusions: Satisfaction does not correlate well with other PROMs, and it might be subject to other external factors not directly related to treatment. Even if patient satisfaction is important in evaluating well-being and patient's experience with medical care, it should not be considered as an isolated proxy to measure quality of treatment. [ABSTRACT FROM AUTHOR]

Background: To compare clinical effect and safety between posterior fossa decompression with duraplasty (PFDD) and posterior fossa decompression without duraplasty (PFD) in treatment of Chiari type I malformation and basilar impression.Methods: A comprehensive computer search was conducted from 2000 to 2019. The quality assessment was performed by the QUADAS-2 tool. The clinical value of comparison between PFDD and PFD was evaluated by using the pooled estimate of sensitivity and specificity. In addition, sensitivity analysis and bias analysis were applied to ensure the accuracy of the results.Results: Finally, 468 patients were enrolled in 6 studies and ultimately met the eligibility criteria. The PFDD and PFD groups were 282 and 186, respectively. The meta-analysis showed no significant difference in the Chicago Chiari Outcome Scale (COSS score) (MD = 0.14, 95% CI [-0.23, 0.50], P = 0.47; P = heterogeneity = 0.86, I2 = 0%). Meanwhile, Significant difference existed in length of stay (MD = -1.08, 95% CI [-1.32, -0.84], P = 0.001; heterogeneity P < 0.000001, I2 = 85%) and complications (OR = 0.35, 95%CI [0.20, 0.62], P = 0.0003; P for Heterogeneity = 0.04, I2 = 56%).Conclusion: PFD is a more efficient and safer therapy than PFDD in the treatment of Chiari type I malformation with basilar impression. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to clarify the association between cervical spondylotic myelopathy (CSM) and cervical arteriosclerosis using ultrasonography that comprehensively includes spinal cord stenosis.Methods: Eighty-two consecutive patients aged over 60 years who underwent spine surgery were divided into those with CSM (n = 31; CSM group) and those with lumbar spinal stenosis without cervical myelopathy (n = 51; LSS group). Maximum spinal cord compression (MSCC) was evaluated for cervical stenosis severity using magnetic resonance (MR) images. The intima-media thickness (IMT) of the common carotid artery (CCA) and pulsatility index (PI) of the bilateral internal carotid artery (ICA) and vertebral artery (VA) were evaluated for cervical arteriosclerosis using pulsed-wave Doppler ultrasonography. Symptom severity was evaluated using the Japanese Orthopaedic Association (JOA) score. Spearman's correlation coefficient was used to determine the relationship between the JOA score and MSCC or IMT and PI in each group. Stepwise multiple linear regression analyses were conducted with the JOA score as a dependent variable and age, sex, body mass index, cervical arteriosclerosis assessment, and MSCC as independent variables.Results: Bilateral IMT and left-side ICA-PI were significantly negatively correlated with JOA scores in the CSM group (Right-CCA-IMT: R =  - 0.412, Left-IMT: R =  - 0.549, Left-ICA -PI: R =  - 0.205, P < 0.05), but not in the LSS group. Multiple linear regression analyses showed that CCA-IMT was the strongest independent factor associated with the preoperative JOA score.Conclusions: Cervical arteriosclerosis was associated with preoperative clinical symptoms in CSM patients. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the current study was to investigate the extent of smartphone use, possible correlation with neck pain and/or psychological impairment in office workers.Method: A convenience sample of 1,602 office workers who were using smartphone for prolonged periods (≥ 4 years) participated in a cross-sectional report of a cohort study, assessing demographic, abnormal symptoms of pain in the neck, physical activity, and psychological behavior characteristics. Participants were assessed using a short version of the Smartphone Addiction Scale (SAS-SV), Depression, Anxiety and Stress Scales (DASS-42) questionnaire, as well as International Physical Activity Questionnaire-Short Form (IPAQ-SF). Multiple logistic regression model was conducted to evaluate the adjusted effect of smartphone overuse on nuchal symptoms.Results: The prevalence of neck pain among the office workers was 30.1%. Significantly more female (33.3% vs. 24.5%) and younger (42.2 vs. 43.2 years) employees reported to have neck pain. Overall in 326 (20.3%, 95% CI: 18.4%-22.4%) of studied subjects had, SAS score ≥ 31 and ≥ 33 for male and females, respectively, and so smartphone overuse (SO) was diagnosed. The results of multiple logistic regression model revealed that those with SO were approximately 6 times more likely to have neck pain (95% CI: 4.44-8.09, P < 0.001).Conclusions: Smartphone overuse in office workers significantly increases the chance of neck pain by 6 times. Hence SO has been associated with, not only somatic complaints, but also psychological distress such as anxiety, stress, and depression. This may necessitate adherence to neck-school, when smartphone use is associated with neck pain. [ABSTRACT FROM AUTHOR]

Introduction: Being able to quantify the invasiveness of a surgical procedure is important to weigh up its associated risks, since invasiveness governs the blood loss, operative time and likelihood of complications. Mirza et al. (Spine (Phila Pa 1976) 33:2651-2661, 2008) published an invasiveness index for spinal surgery. We evaluated the validity of a modified version of the Mirza invasiveness index (mMII), adapted for use with registry data.Methods: A cross-sectional analysis was performed with data acquired from the Spine Tango registry including 21,634 patients. The mMII was calculated as the sum of six possible interventions on each vertebral level: decompression, fusion and stabilization either on anterior or posterior structures. The association between the mMII and blood loss, operative time and complications was evaluated using multiple regression, adjusting for possible confounders.Results: The mean (± SD) mMII was 3.9 ± 5.0 (range 0-40). A 1-point increase in the mMII was associated with an additional blood loss of 12.8% (95% CI 12.6-13.0; p < 0.001) and an increase of operative time of 10.4 min (95% CI 10.20-10.53; p < 0.001). The R2 for the blood loss model was of 43% and for operative time, 47%. The mean mMII was significantly (p < 0.001) higher in patients with surgical complications (4.5 ± 5.6) and general medical complications (6.5 ± 7.0) compared to those without (3.8 ± 4.9). Our results were comparable to those reported in the original publication of Mirza et al. CONCLUSION: The mMII appeared to be a valid measure of surgical invasiveness in our study population. It can be used in predictor models and to adjust for surgical case-mix when comparing outcomes in different studies or different hospitals/surgeons in a registry. [ABSTRACT FROM AUTHOR]

Purpose: To investigate GAP scores in an asymptomatic cohort of adults, including older adults with age-expected changes in spinal alignment.Methods: One hundred and twenty asymptomatic volunteers underwent full-body radiographic scans. Demographics and sagittal radiographic parameters (pelvic incidence, sacral slope, L1-S1 lordosis, L4-S1 lordosis, and global tilt) were measured and GAP scores calculated ( www.gapcalculator.com ). Mann-Whitney U test compared groups.Results: Eighty-five individuals (65 female, average age 48 ± 16 years, BMI 27 ± 6 kg/cm2) were analyzed. The median GAP score was that of a proportioned spine (0, range 0-10). 20% were moderately disproportioned and 6% were severely disproportioned. The mean relative pelvic version, relative lumbar lordosis (RLL), lumbar distribution index (LDI), and relative spinopelvic alignment were all considered aligned, although the mean RLL and LDI scores were both greater than 1. When categorized by age (< 60 years, ≥ 60 years), the median GAP score of the younger group was 0 (normal), while the median GAP score of the older cohort was 1 (normal) and different from the younger group (p < 0.001).Conclusion: Most patients in this asymptomatic, nonoperative cohort were normally proportioned. However, a large percentage of asymptomatic volunteers were moderately or severely disproportioned. Older patients had higher scores, indicating some disproportion. There was also a small number of severely sagittally misaligned and poorly proportioned, yet asymptomatic, volunteers. Further refinement of individualized targets is needed to determine the effect on mechanical complications and quality of life given the divergent recommendations of age-adjusted targets and GAP targets. [ABSTRACT FROM AUTHOR]

Purpose: Reach a consensus on which diagnostic tests are most important in confirming the clinical diagnosis of lumbar spinal stenosis (LSS).Methods: Phase 1: 22 members of the International Taskforce on the Diagnosis and Management of LSS confirmed 35 diagnostic items. An on-line survey was developed that allows experts to express the logical order in which they consider the diagnostic tests, and the level of certainty ascertained from each test. Phase 2, Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 15 members of Taskforce defined final list of 10 items. Round 3: Survey was distributed internationally, followed by Taskforce consensus.Results: Totally, 432 clinicians from 28 different countries participated. Certainty of the diagnosis was 60% after selecting the first test and significant change in certainty ceasing after eight items at 90.8% certainty (p < 0.05). The most frequently selected tests included MRI/CT scan, neurological examination and walking test with gait observation. The diagnostic test selected most frequently as the first test was neurological examination.Conclusions: This is the first study to reach an international consensus on which diagnostic tests should be used in the clinical diagnosis of LSS. The final recommendation includes three core diagnostic items: neurological examination, MRI/CT and walking test with gait observation. The Taskforce also recommends 3 'rule out' tests: foot pulses/ABI, hip examination and test for cervical myelopathy. If applied, this core set of diagnostic tests can standardize outcomes and improve clinical care of LSS globally. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to investigate, using a meta-analysis, differences in safety and effectiveness between a titanium mesh bone graft and bone graft alone for the treatment of thoracolumbar spinal tuberculosis.Methods: PubMed, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang (Chinese) and other databases were searched up to April 2019 using predetermined terms. Published studies investigating the safety and effectiveness of a titanium mesh bone graft versus a bone graft alone for the treatment of thoracolumbar spinal tuberculosis were included. Two authors independently extracted the data and evaluated the quality of the included articles. A meta-analysis of relevant outcome indicators was performed using Stata 14 and RevMan 5.3 software.Results: We retrieved 8 retrospective studies that met the inclusion criteria and enrolled a total of 401 patients, including 203 patients in the titanium mesh group and 198 in the bone graft only group. Each study was rated as high quality. The meta-analysis results showed no statistically significant differences between the 2 bone graft methods in terms of surgery-related indicators, clinical effectiveness, imaging and complications.Conclusions: Both titanium mesh and bone grafts alone are effective for the treatment of thoracolumbar spinal tuberculosis based on safety. However, the results of this study do not support the superiority of titanium mesh bone grafts reported in previous studies. Because of the high risk of bias of the conclusions of a meta-analysis of non-randomized studies and the small sample sizes for some of the most important outcomes, randomized controlled trials are expected to further examine the reliability of the present findings. [ABSTRACT FROM AUTHOR]

Purpose: Existing automated spine alignment is based on original X-rays that are not applicable for teleradiology for spinal deformities patients. We aim to provide a novel automated vertebral segmentation method enabling accurate sagittal alignment detection, with no restrictions imposed by image quality or pathology type.Methods: A total of 428 optical images of original sagittal X-rays taken by smartphones or screenshots for consecutive patients attending our spine clinic were prospectively collected. Of these, 300 were randomly selected and their vertebrae were labelled with Labelme. The ground truth was specialists measured sagittal alignment parameters. Pre-trained Mask R-CNN was fine-tuned and trained to predict the vertebra level(s) on the remaining 128 testing cases. The sagittal alignment parameters including the thoracic kyphosis (TK), lumbar lordosis (LL) and sacral slope (SS) were auto-detected, based on the segmented vertebra. Dice similarity coefficient (DSC) and mean intersection over union (mIoU) were calculated to evaluate the accuracy of the predicted vertebra. The detected sagittal alignments were then quantitatively compared with the ground truth.Results: The DSC was 84.6 ± 3.8% and mIoU was 72.1 ± 4.8% indicating accurate vertebra prediction. The sagittal alignments detected were all strongly correlated with the ground truth (p < 0.001). Standard errors of the estimated parameters had a small difference from the specialists' results (3.5° for TK and SS; 3.4° for LL).Conclusion: This is the first study using fine-tuned Mask R-CNN to predict vertebral locations on optical images of X-rays accurately and automatically. We provide a novel alignment detection method that has a significant application on teleradiology aiding out-of-hospital consultations. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: Numerous candidate genes and single-nucleotide polymorphisms (SNPs) have been identified in the background of lumbar disc degeneration (LDD). However, in most of these underpowered studies, definitions of LDD are inconsistent; moreover, many of the findings have not been replicated and are contradictory. Our aim was to characterize LDD by well-defined phenotypes and possible endophenotypes and analyse the association between these and candidate vitamin D receptor (VDR) gene polymorphisms on a large (N = 1426) dataset.Methods: Seven candidate VDR SNPs were genotyped. Individual association, haplotype and gene-gene interaction analyses were performed. All degenerative endophenotypes were significantly associated with one or more candidate VDR gene variants.Results: Haplotype analyses confirmed the association between the 3'-end VDR variants (BsmI, ApaI, TaqI) and Modic changes as well as the relationship of 5'-end variants (Cdx2, A1012G) with endplate defects. We also found significant interactions between the 3'- and 5'-end regulatory regions and endplate defects. Based on our results, VDR and its gene variants are highly associated with specific degenerative LDD endophenotypes.Conclusion: Understanding relationships between phenotype and gene variants is crucial for describing the pathways leading to the multifactorial, polygenic degeneration process and LDD-related conditions. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: This longitudinal study followed 10- to 13-year-old adolescents for 5 years to investigate the effects of juvenile musculoskeletal (MSK) pain and psychosocial risk factors on future pain. We further predicted that increased MSK pain at follow-up would be positively related to current school pressure at follow-up and negatively related to current sleep quality. Sleep quality was tested as a potential mediator of the link between school pressure and MSK pain at follow-up after controlling for baseline MSK pain.Methods: The baseline sample comprised 189 adolescents, and 5-year follow-up resulted in 107 15- to 18-year-old adolescents who had completed mandatory education. Adolescents responded to an online questionnaire about psychosocial stressors, MSK pain, school achievement and leisure activities. A longitudinal hierarchic linear regression including all significant baseline predictors was run to assess their impact on MSK pain 5 years later. Mediation analysis was used to investigate sleep quality as a potential mediator of the relationship between school pressure and MSK pain at follow-up.Results: Baseline MSK pain predicted MSK pain over a time lag of 5 years (ß = .26, p = .02). The relationship between follow-up school pressure and current MSK pain was mediated by sleep quality at follow-up (B = .17, SEB = .07, 95% CI .06-.34) when baseline MSK pain was controlled.Conclusions: Juvenile MSK pain predicts MSK pain in adolescence. A psychosocial mediation model including school pressure and sleep impairments has the potential to explain MSK pain mechanisms in adolescents. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the association between plasma levels of inflammatory cytokines (interleukin [IL]-1-β, IL-6, tumor necrosis factor [TNF]-α, and the soluble TNF receptor 1 [sTNF-R1]), disability, and risk of falls in older women with acute low back pain (LBP).Methods: This cross-sectional study comprised a subsample of older women from the Back Complaints in the Elders international cohort study. Plasma levels of IL-1-β, IL-6, TNF-α, and sTNF-R1 were measured using enzyme-linked immunosorbent assays. Pain was assessed using the Numerical Pain Scale and McGill Pain Questionnaire, while disability was measured using the Roland Morris Questionnaire and gait speed. Risk of falls was estimated using the Physiological Profile Assessment. Linear regression model was used to verify the association between independent variables and fall risk.Results: One hundred and ten women (aged 69.97 ± 5.5 years) with acute LBP were included. The regression model showed an association between the risk of falls and IL-6 levels, pain, gait speed, and years of education. It also explained 21.2% of risk of falls variance. The model equation was: fall risk = 1.28 + (0.19 IL-6) + (0.02 quality of pain) + (- 0.71 gait speed) + (-0 .17 educational level).Conclusions: This study showed an association between risk of falls and IL-6, pain, gait speed, and educational level in older women with LBP. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Background and Aim: Growing attention is being given to physical functioning measures to assess interventions for low back pain (LBP). The Quebec Back Pain Disability Questionnaire (QBPDS) has never been validated in Italian patients, and the aim of the study was culturally adapting and validating the Italian version of the QBPDS (QBPDS-I), to allow its use with Italian-speaking patients with chronic LBP.Methods: The QBPDS-I was developed by means of forward-backward translation, a final review by an expert committee and a test of the prefinal version to evaluate its comprehensibility. The psychometric testing included structural validity by exploratory factor analysis (EFA), reliability by internal consistency (Cronbach's alpha) and test-retest reliability (intraclass correlation coefficient, ICC 2.1), measurement error by calculating the minimum detectable change (MDC), construct validity by assessing hypotheses of QBPDS correlations with the Roland Morris Disability Scale (RMDQ), the Oswestry Disability Questionnaire (ODI) and a pain numerical rating scale (NRS) (Spearman's correlations).Results: It took one month to develop a consensus-based version of the QBPDS-I. The questionnaire was administered to 201 subjects with chronic LBP and was well accepted. EFA suggested a one-factor 20-item solution (first factor variance explained = 54.7%). Internal consistency (α = 0.95) and test-retest reliability (ICC = 0.90) were excellent. The MDC was 12 scale points. Construct validity was good as all of the hypotheses were met; correlations: RMDQ (r = 0.40), ODI (r = 0.48) and NRS (r = 0.44).Conclusions: The QBPDS-I is unidimensional, reliable and valid in patients with chronic LBP. Its use is recommended for clinical and research purposes. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to quantify the stabilizing effect of the passive structures in thoracic spinal motion segments by stepwise resections. These data can be used to calibrate finite element models of the thoracic spine, which are needed to explore novel surgical treatments of spinal deformities, fractures, and tumours.Method: Six human thoracic spinal motion segments from three segmental levels (T2-T3, T6-T7, and T10-T11) were loaded with pure moments of 1 and 2.5 Nm in flexion/extension, lateral bending, and axial rotation. After each loading step, the ligaments, facet capsules, and the nucleus pulposus were stepwise resected from posterior to anterior direction, while the segmental relative motions were measured using an optical motion tracking system.Results: Significant increases (p < 0.05) in the range of motion were detected after resecting the anterior spinal structures depending on loading magnitude, motion direction, and segmental level. The highest relative increases in the range of motion were observed after nucleotomy in all motion directions. The vertebral arch mostly stabilized the thoracic spinal motion segments in flexion and extension, while the facet joint capsules mainly affected the segmental stability in axial rotation. Coupled motions were not observed.Conclusions: The anulus fibrosus defines the motion characteristics qualitatively, while the ligaments and the presence of the nucleus pulposus restrict the mobility of a thoracic spinal motion segment solely in a quantitative manner. The posterior ligaments do not predominantly serve for primary stability but for the prevention of hyperflexion. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: To assess pain, health-related quality of life (HRQOL) scores and sagittal parameters of adult spinal deformity (ASD)-operated patients in the context of their analgesic consumption especially opioids (narcotics) over the first year postoperative period.Methods: In total, 372 patients from a multicenter database were stratified into 3 groups at baseline: 241 patients in the minimal group (no analgesic, or NSAIDs/narcotics weekly or less), 64 in the NSAIDs every day group and 67 in the narcotics every day group. HRQOL and back and leg pain scores were evaluated at 6 months and 1 year postoperatively. Also several sagittal alignment parameters were assessed.Results: Significant improvements in pain and HRQOL scores were observed across all 3 groups by 1 year (P < 0.05) postoperatively. While the minimal group had the best pre- and postoperative HRQOL scores, the NSAID group demonstrated the best improvement in HRQOL. Only the minimal group displayed continued improvement from 6 months to 1 year. 90%, 65% and 40% of minimal, NSAID and narcotic groups of patients, respectively, no longer took any analgesics at 1 year postoperatively. Alternatively, 36% of patients in the narcotics group continued to take narcotics at 1 year. Residual malalignment increased NSAIDs consumption in different groups at 1 year.Conclusion: This study evaluated the analgesics use after ASD surgery in relation to the clinical and radiological outcomes. Despite important postoperative opioids consumption in the narcotics group, clinical outcome yet improved. Malalignment parameters demonstrated a predictive value in regard to NSAIDs' usage. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: To build a mathematical model which could calculate the desired laminoplasty opening size (LOS) based on the target sagittal canal diameter (SCD) before single-door cervical laminoplasty (SDCL) when taking the effects of surgery drill into consideration.Methods: The model was based on geometric analysis on deformation of spinal canal; the formula was derived and characterized as: y (mm) = 2 [Formula: see text] × sin(β/2) = c - d (y is the size of LOS, [Formula: see text] the size of transverse canal diameter, β the size of laminoplasty opening size, c the size of mini-plate and d the diameter of the drill bit used during the surgery operation). The parameters of pre- and postoperative computed tomography scans of 20 patients who had undergone SDCL were measured by the picture archiving and communication system (PACS) software and a new instrument named as Lei's ruler, respectively.Results: The effects of surgery SDCL were very significant; for each patient, the SCD was enlarged dramatically after the surgery (P < 0.01). The differences between the data obtained by PACS and Lei's ruler were no statistically significant (P > 0.05). According to the derived formula, the 95% confidence intervals of SCD after the surgery were within the range of 14 mm and 14.5 mm.Conclusion: Applying the mathematical model and derived formula, the desired LOS could be calculated according to the target SCD which could help the surgeon select an optimum mini-plate before SDCL. At the same time, a new measuring device named Lei's ruler is designed for the convenience of the derived formula. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: To clarify the clinical features, surgical strategies, and outcomes of intraosseous schwannoma (IOS) of the mobile spine.Methods: We retrospectively reviewed patients with primary benign spinal schwannoma who underwent surgery in our orthopedic department.Results: A total of 101 patients with primary benign schwannoma located in the mobile spine underwent surgery in our orthopedic department from 2005 to 2015. Twenty-five patients presented with aggressive features. Twenty patients were regularly followed up, twelve with lesions in the cervical spine, six with lesions in the thoracic region, and two with lesions in the lumbar spine. Preoperative CT-guided biopsy was performed in fourteen cases; the accuracy of diagnosis was 100%, and IOS is not histologically different from conventional schwannoma. The computed tomography (CT) scan revealed expansile and osteolytic bone destruction in all these cases, with six patients having pathological fracture. On T2-weighted magnetic resonance imaging, the lobulated schwannomas showed heterogeneous signal intensity and significant heterogeneous enhancement on post-contrast images. Gross total resection was performed in seventeen patients and subtotal resection in three. Tumor-involved nerve roots resection were documented to decrease local recurrence in fourteen cases. The visual analog scale score decreased from 5.66 ± 1.79 preoperatively to 1.16 ± 1.77 at the final follow-up. No local recurrence was noticed at the final follow-up.Conclusion: CT-guided biopsy is effective for the preoperative diagnosis of spinal IOS. Total resection is the optimal treatment for IOS, whereas subtotal resection could be an alternative choice for high-risk cases. These slides can be retrieved under electronic supplementary material. [ABSTRACT FROM AUTHOR]

Purpose: To investigate F-wave as a method to identify a specific root lesion of L5 or S1 and to quantitatively evaluate the severity and progression of motor root lesions in lumbosacral radiculopathies (LR).Methods: Both peroneal and tibial F-waves were performed bilaterally in 142 patients with unilateral L5 or S1 radiculopathies and 37 controls along with Medical Research Council (MRC) evaluation, and soleus H-reflexes were tested bilaterally in 78 of these 142 cases. Both F-wave and MRC were re-evaluated approximately 1 year after initial examination in 65 patients.Results: Abnormal peroneal F-waves were found in 34 patients with L5 radiculopathy (34/67, 50.7%) along with normal tibial F-waves and soleus H-reflexes in all tested cases. By contrast, 27 patients with S1 radiculopathy presented abnormal tibial F-waves (27/76, 36.0%) along with normal peroneal F-waves in all 76 cases and abnormal soleus H-reflexes in 38 of 47 (80.9%) cases. There were significant differences in involved side F-duration among different MRC scales in both radiculopathy groups (P < 0.05). Follow-up analysis demonstrated slow progression of both F-wave abnormalities and muscle weakness in patients undergoing conservative treatment (P < 0.05).Conclusions: Comparisons of F-waves between the same nerve on both sides and between peroneal and tibial nerves in the same leg may clearly increase the validity of F-waves for evaluating a specific motor root lesion of L5 or S1. Furthermore, a quantitative comparison of F-waves may provide additional information on the severity of individual root lesions and their progression even in the early stages of disease. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: The presence of prominent OALL (ossification of anterior longitudinal ligament) in the anterior cervical spine has been implicated as a cause of dysphagia. Surgical resection of the OALL is considered effective for the management of diffuse idiopathic skeletal hyperostosis (DISH)-related dysphagia. Although many reports have been published on DISH-related dysphagia, no cases of postoperative cervical instability have been reported thus far. We present a case in which the patient developed myelopathy associated with instability consequent to resection of OALL in DISH.Methods: A 62-year-old man presented with progressive dysphagia that persisted for a year. The patient's symptoms were successfully resolved by resection of OALL. Five years after the surgery, the dysphagia resurfaced and was found to be caused by the regrowth of the OALL. A repeat surgery was performed, and the dysphagia disappeared. Eleven months after the second surgery, he visited the hospital with progressive quadriparesis and pain in the cervical region.Results: Nine-month follow-up radiologic study revealed cervical instability at the level of C5-6 resulting in myelopathy. The patient underwent decompressive laminectomy and posterior fusion surgery.Conclusion: Surgical resection of DISH-related dysphagia typically yields excellent outcomes, but our experience in this case highlights the possibility of OALL regrowth and subsequent cervical instability after resection of OALL. [ABSTRACT FROM AUTHOR]

Purpose: Chiropractic care is popular for low back pain, but may increase the risk for acute lumbar disc herniation (LDH). Low back pain is a common early (prodromal) symptom of LDH and commonly precedes LDH diagnosis. Our objective was to investigate the association between chiropractic care and acute LDH with early surgical intervention, and contrast this with the association between primary care physician (PCP) care and acute LDH with early surgery.Methods: Using a self-controlled case series design and population-based healthcare databases in Ontario, Canada, we investigated all adults with acute LDH requiring emergency department (ED) visit and early surgical intervention from April 1994 to December 2004. The relative incidence of acute LDH with early surgery in exposed periods after chiropractic visits relative to unexposed periods was estimated within individuals, and compared with the relative incidence of acute LDH with early surgery following PCP visits.Results: 195 cases of acute LDH with early surgery (within 8 weeks) were identified in a population of more than 100 million person-years. Strong positive associations were found between acute LDH and both chiropractic and PCP visits. The risk for acute LDH with early surgery associated with chiropractic visits was no higher than the risk associated with PCP visits.Conclusions: Both chiropractic and primary medical care were associated with an increased risk for acute LDH requiring ED visit and early surgery. Our analysis suggests that patients with prodromal back pain from a developing disc herniation likely seek healthcare from both chiropractors and PCPs before full clinical expression of acute LDH. We found no evidence of excess risk for acute LDH with early surgery associated with chiropractic compared with primary medical care. [ABSTRACT FROM AUTHOR]

Purpose: Lumbar spinal canal stenosis (LSCS) is associated with fibrosis, decreased elastin-to-collagen ratio, and hypertrophy of the ligamentum flavum (LF). Diabetes mellitus (DM) is known to cause metabolic disturbances within the extracellular matrix in multiple tissues. These alterations may play a major role in the severity of clinical symptoms of LSCS affecting diabetic patients. We aimed to examine the hypothesis that DM may contribute to the LF changes seen in patients with LSCS.Methods: The study cohort included 29 patients: 23 with LSCS (10 with DM vs. 13 without DM) as well as six patients with lumbar disc herniation (LDH). Surgical LF specimens were retrieved for histological assessment. Morphologic quantification of confocal microscopy images using fast Fourier transform analysis allowed us to compare anisotropy and elastin fiber orientation between groups.Results: There was a significant positive correlation between fasting plasma glucose values and degree of elastin degradation (r = 0.36, p = 0.043). The diabetic patients with LSCS showed a significantly greater loss of elastic fibers (2.3 ± 0.9 vs. 1.5 ± 0.55, p = 0.009), although fibrosis was shown to be similar (1.44 ± 0.7 vs. 1.43 ± 0.88, p = 0.98). There was no significant difference in the degree of calcification in the LSCS group between patients with and without diabetes (1.71 vs. 2.05%, p = 0.653). Fiber orientation was found to be less homogenous in the LSCS compared with the LDH group, although not significantly affected by DM.Conclusions: The present study points to a significant contribution of DM to the loss of elastin fibers that occurs in the LF of patients with LSCS. [ABSTRACT FROM AUTHOR]

Purpose: Chiropractic spinal manipulation treatment (SMT) is common for back pain and has been reported to increase the risk for lumbar disc herniation (LDH), but there is no high quality evidence about this. In the absence of good evidence, clinicians can have knowledge and beliefs about the risk. Our purpose was to determine clinicians' beliefs regarding the risk for acute LDH associated with chiropractic SMT.Methods: Using a belief elicitation design, 47 clinicians (16 chiropractors, 15 family physicians and 16 spine surgeons) that treat patients with back pain from primary and tertiary care practices were interviewed. Participants' elicited incidence estimates of acute LDH among a hypothetical group of patients with acute low back pain treated with and without chiropractic SMT, were used to derive the probability distribution for the relative risk (RR) for acute LDH associated with chiropractic SMT.Results: Chiropractors expressed the most optimistic belief (median RR 0.56; IQR 0.39-1.03); family physicians expressed a neutral belief (median RR 0.97; IQR 0.64-1.21); and spine surgeons expressed a slightly more pessimistic belief (median RR 1.07; IQR 0.95-1.29). Clinicians with the most optimistic views believed that chiropractic SMT reduces the incidence of acute LDH by about 60% (median RR 0.42; IQR 0.29-0.53). Those with the most pessimistic views believed that chiropractic SMT increases the incidence of acute LDH by about 30% (median RR 1.29; IQR 1.11-1.59).Conclusions: Clinicians' beliefs about the risk for acute LDH associated with chiropractic SMT varied systematically across professions, in spite of a lack of scientific evidence to inform these beliefs. These probability distributions can serve as prior probabilities in future Bayesian analyses of this relationship. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to analyze rates of perioperative complications and subsequent cervical surgeries in patients treated for cervical degenerative disc disease with anterior cervical discectomy and fusion (ACDF) and those treated with artificial cervical disc arthroplasty (ACDA) for up to 5-year follow-up.Methods: California's Office of Statewide Health Planning and Development discharge database was analyzed for patients aged 18-65 years undergoing single-level ACDF or ACDA between 2003 and 2010. Medical comorbidities were identified with CMS-Condition Categories. Readmissions for short-term complications of the procedure were identified and rates of subsequent cervical surgeries were calculated at 90-day and 1-, 3-, and 5-year follow-up. Multivariate regression modeling was used to identify associations with complications and subsequent cervical surgeries correcting for patient and provider characteristics.Results: A total of 52,395 eligible cases were identified: 50,926 ACDF and 1469 ACDA. Readmission was less common in the ACDA group (OR: 0.69, 95% CI: 0.48-1.0, p = 0.048). Subsequent cervical spine surgery was more common in the ACDF group in the immediate perioperative period (within 90 days of surgery) (ACDF 3.35% vs. ACDA 2.04%, OR: 0.63, 95% CI: 0.44-0.92, p = 0.015). At 1-, 3-, and 5-year postoperatively, rates of subsequent cervical surgeries were similar between the two cohorts.Conclusions: We found no protective benefit for ACDA versus ACDF for single-level disease at up to 5-year follow-up in the largest cohort of patients examined to date. Early complications were rare in both cohorts stressing the value of large cohort studies to study risk factors for rare events. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: During the long-term practice of percutaneous endoscopic cervical discectomy (PECD) at our institution, we have modified the protocol to include the vertical anchoring technique (VAT), which we will describe in detail in this article. The objective of this study was to compare the clinical outcomes associated with the conventional posterior PECD technique with that associated with the modified technique to determine the safety and efficacy of the latter technique.Methods: From December 2014 to January 2016, a total of 44 patients with single cervical disc herniation were randomly divided into two groups. One group underwent conventional posterior PECD, and the other group underwent posterior PECD combined with VAT. The operative time, fluoroscopy times and perioperative complications were recorded. The visual analog scale (VAS) for neck and arm pain and the modified MacNab criteria at 1 day, 3, 6, and 12 months after surgery were used to evaluate the postoperative outcomes.Results: All patients underwent surgery successfully without severe complications. The operative time and intraoperative fluoroscopy times were significantly less in patients treated with VAT than in those who underwent conventional posterior PECD (P < 0.05). Both types of surgery significantly improved the symptoms of patients. According to the results of the follow-up period, there were no significant differences in VAS scores for neck and arm pain or the modified MacNab criteria between the two groups (P > 0.05). There was no recurrence in either group during the follow-up period.Conclusions: Although the clinical outcomes of the two surgical techniques were similar, the VAT decreased the operative time and intraoperative fluoroscopy times in posterior PECD surgery. The learning curve for posterior PECD could be shortened by using the VAT. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this research is to compare the clinical efficacy, postoperative complication and surgical trauma between anterior cervical corpectomy and fusion versus posterior laminoplasty for the treatment of oppressive myelopathy owing to cervical ossification of the posterior longitudinal ligament (OPLL).Study Design: Systematic review and meta-analysis.Methods: An comprehensive search of literature was implemented in three electronic databases (Embase, Pubmed, and the Cochrane library). Randomized or non-randomized controlled studies published since January 1990 to July 2017 that compared anterior cervical corpectomy and fusion (ACCF) versus posterior laminoplasty (LAMP) for the treatment of cervical oppressive myelopathy owing to OPLL were acquired. Exclusion criteria were non-human studies, non-controlled studies, combined anterior and posterior operative approach, the other anterior or posterior approaches involving cervical discectomy and fusion and laminectomy with (or without) instrumented fusion, revision surgeries, and cervical myelopathy caused by cervical spondylotic myelopathy. The quality of the included articles was evaluated according to GRADE. The main outcome measures included: preoperative and postoperative Japanese Orthopedic Association (JOA) score; neuro-functional recovery rate; complication rate; reoperation rate; preoperative and postoperative C2-C7 Cobb angle; operation time and intraoperative blood loss; and subgroup analysis was performed according to the mean preoperative canal occupying ratio (Subgroup A:the mean preoperative canal occupying ratio < 60%, and Subgroup B:the mean preoperative canal occupying ratio ≥ 60%).Results: A total of 10 studies containing 735 patients were included in this meta-analysis. And all of the selected studies were non-randomized controlled trials with relatively low quality as assessed by GRADE. The results revealed that there was no obvious statistical difference in preoperative JOA score between the ACCF and LAMP groups in both subgroups. Also, in subgroup A (the mean preoperative canal occupying ratio < 60%), no obvious statistical difference was observed in the postoperative JOA score and neurofunctional recovery rate between the ACCF and LAMP groups. But, in subgroup B (the mean preoperative canal occupying ratio ≥ 60%), the ACCF group illustrated obviously higher postoperative JOA score and neurofunctional recovery rate than the LAMP group (P < 0.01, WMD 1.89 [1.50, 2.28] and P < 0.01, WMD 24.40 [20.10, 28.70], respectively). Moreover, the incidence of both complication and reoperation was markedly higher in the ACCF group compared with LAMP group (P < 0.05, OR 1.76 [1.05, 2.97] and P < 0.05, OR 4.63 [1.86, 11.52], respectively). In addition, the preoperative cervical C2-C7 Cobb angle was obviously larger in the LAMP group compared with ACCF group (P < 0.05, WMD - 5.77 [- 9.70, - 1.84]). But no statistically obvious difference was detected in the postoperative cervical C2-C7 Cobb angle between the two groups. Furthermore, the ACCF group showed significantly more operation time as well as blood loss compared with LAMP group (P < 0.01, WMD 111.43 [40.32,182.54], and P < 0.01, WMD 111.32 [61.22, 161.42], respectively).Conclusion: In summary, when the preoperative canal occupying ratio < 60%, no palpable difference was tested in postoperative JOA score and neurofunctional recovery rate. But, when the preoperative canal occupying ratio ≥ 60% ACCF was associated with better postoperative JOA score and the recovery rate of neurological function compared with LAMP. Synchronously, ACCF in the cure for cervical myelopathy owing to OPLL led to more surgical trauma and more incidence of complication and reoperation. On the other hand, LAMP had gone a diminished postoperative C2-C7 Cobb angle, that might be a cause of relatively higher incidence of postoperative late neurofunctional deterioration. In brief, when the preoperative canal occupying ratio < 60%, LAMP seems to be effective and safe. However, when the preoperative canal occupying ratio ≥ 60%, we prefer to choose ACCF while complications could be controlled by careful manipulation and advanced surgical techniques. No matter which option you choose, benefits and risks ought to be balanced. [ABSTRACT FROM AUTHOR]

Purpose: Severe scoliosis is primarily managed with surgery. This cohort study describes the incidence of surgically treated scoliosis among Swedish youth and young adults, stratified by age, sex, scoliosis type, and surgical approach and identifies changes in incidence rate and hospital length of stay (LOS), infections requiring re-surgery and mortality within 90 days.Methods: Swedish youth, 0-21 years, (n = 3062) with a diagnostic code for scoliosis and spine surgery between 2000 and 2013 were selected from the National Patient Register. Incidence was computed by comparing individuals with surgically treated scoliosis to the total at risk population. Linear regression models and Spearman correlation coefficients analyzed trends over time.Results: Overall annual incidence per 100,000 individuals was 9.1 (5.9 males/12.5 females). Annual incidence increased over 14 years from 5.1 to 9.8; an average 4.6% per year (p < 0.001). Adolescent idiopathic scoliosis was most common (4.5 per 100,000; n = 1516) followed by neuromuscular 2.7 (n = 913) and congenital 0.7 (n = 236). Average LOS decreased among scoliosis types except infantile and neuromuscular scoliosis. Posterior fusion was the most common surgical approach (75%) followed by anterior (18%) and anteroposterior fusion (7%). Posterior fusions significantly increased with a resultant decrease in anterior and anteroposterior fusion over time. Individuals with neuromuscular scoliosis exhibited the highest mortality (n = 12; 1.3%) and (n = 59; 6%) of individuals with neuromuscular scoliosis and (n = 12; 15%) with scoliosis related to MMC required revision surgery due to post-op infection.Conclusions: Surgical management of scoliosis is increasing with a concurrent decrease in hospital LOS. Surgical management of neuromuscular scoliosis is associated with high 90-day post-operative infections and mortality rate. [ABSTRACT FROM AUTHOR]

Purpose: A long debate exists about the connection between anorexia nervosa (AN) and scoliosis due to conflicting evidence. No study so far has evaluated the prevalence of scoliosis in patients with AN. The aim of the study is to evaluate the prevalence of idiopathic scoliosis in patients with AN.Methods: Design: cross-sectional study.Study Group: convenience sample of all patients matching the inclusion criteria.Control Group: female participants coming from an epidemiological screening for scoliosis.Inclusion Criteria: patients had a diagnosis of AN during adolescence according to the DSM-IV-TR criteria. We applied a two-level screening using a Bunnell scoliometer and a radiograph. We calculated the odds ratio compared with participants coming from a school screening.Results: Seventy-seven females with AN were compared to 816 females screened for scoliosis. The prevalence of scoliosis in the AN group was 16.9% (OR 5.77, 95% CI 3.12-10.67) with respect to the control group. If we consider as positive only those who received a scoliosis diagnosis during adolescence, the OR would be 3.15 (95% CI 1.55-6.42).Discussion: This is the first study performed on patients with AN showing a sixfold greater odds of presenting with scoliosis. A cause-effect relationship cannot be determined due to the design. [ABSTRACT FROM AUTHOR]

Purpose: Sagittal imbalance of severe adult degenerative deformities requires surgical correction to improve pain, mobility and quality of life. Our aim was a harmonic and balanced spine, treating a series of adult degenerative thoracolumbar and lumbar kyphoscoliosis by a non posterior subtraction osteotomy technique.Methods: We operated 22 painful thoracolumbar and lumbar compensated degenerative deformities by anterior (ALIF), extreme lateral (XLIF) and transforaminal (TLIF) interbody fusion and grade 2 osteotomy (SPO) to restore lumbar lordosis and mobilize the coronal curve. Two-stage surgery, first anterior and after 2 or 3 weeks posterior, was proposed when the Oswestry Disability Index (ODI) was equal to or greater than 50% and VAS more than 5. All patients were submitted to X-ray and clinical screening during pre, post-operative and follow-up periods.Results: We performed 5 ALIFs, 39 XLIFs, 8 TLIFs, 32 SPOs. No major complications were recorded and complication rate was 18% after lateral fusion and 22.7% after posterior approach. Pelvic tilt, lumbar lordosis, sagittal vertical axis and thoracic kyphosis improved (p < 0.05). Clinical follow-up (mean 20.5; range 18-24) was satisfactory in all cases, except for two due to sacroiliac pain. Mean preoperative VAS was 7.7 (range 6-10), while ODI was 67% on average (range 50-78). After two-stage surgery, VAS and ODI decreased, respectively, to 2.4 (range 2-4) and 31% (range 25-45), while their values were 4 (range 2-6) and 35% (range 20-55) at the final follow-up.Conclusion: Current follow-up does not allow definitive conclusions. However, the surgical approach adopted in this study seems promising, improving balance and clinical condition of adult patients with a compensated sagittal degenerative imbalance of the thoracolumbar spine. [ABSTRACT FROM AUTHOR]

Introduction: Chronic low back pain is a significant public health issue. Both its direct and indirect cost represents tens of billions of US dollars. Although chronic low back pain can be the result of many factors, the predominant cause is disc degeneration. Recent studies have shown genetic involvement in up to 74% of cases. This study aimed to evaluate genetic risk factors of disc degeneration by performing a systematic analysis of association studies. The objective is to provide a guide for practice by assessing the clinical relevance of current information.Methods and Materials: We performed a meta-analysis of 3122 items collected from 6 databases. 74 articles were selected according to our inclusion criteria. 18 (24%) could be grouped into 16 meta-analyses of 16 mutations in 12 genes. The statistics of the meta-analysis were conducted through Revman 5.1 software.Results: The items included are 10,250 cases and 14,136 controls. The GOLD range from 3.42 to 0.38. Two alleles were significantly associated with disc degeneration: IL-6 rs1800797 and MMP-9 rs17576 and one proved to be protective: IL-6 rs1800795. 13 meta-analyses did not yield significant results and methodological heterogeneity.Discussion: The results highlight the lack of methodological rigor in most of the studies. The absence of international clinical and radiological classification of early disc degeneration, limits the homogeneity of studies. Understanding which populations are predisposed to this significant public health problem may change our approach to diagnostic and therapeutic methods. This work opens up enormous opportunities to provide a genetic solution and consider new diagnostic and therapeutic means to this public health problem. [ABSTRACT FROM AUTHOR]

Purpose: In the present prospective randomized controlled study, we compared the feasibility and effectiveness of our modified thoracoabdominal approach to anterior thoracolumbar spine surgery without cutting open the costal portion of diaphragm (extradiaphragmatic approach) with the traditional transdiaphragmatic thoracoabdominal approach. The traditional combined thoracoabdominal approach in anterior thoracolumbar surgery for spine tuberculosis is effective but seriously damages the diaphragm and causes various lung complications. We used an extradiaphragmatic approach for complete anterior debridement, bone grafting, and nerve decompression and compared its efficacy and complications with those of the traditional transdiaphragmatic thoracolumbar approach.Methods: The study included 106 patients with spinal tuberculosis. After a standard preoperative chemotherapy regimen, all patients underwent posterior deformity correction and internal fixation, anterior debridement, decompression, and bone grafting. Patients were divided into the modified extradiaphragmatic thoracolumbar approach group (the modified group) and the traditional transdiaphragmatic thoracolumbar approach group (the traditional group). During the treatment, we strictly followed the standard chemotherapy regimen.Results: The mean follow-up duration was 36.2 months (range 25-38 months). There were significant differences between the two groups in intraoperative blood loss, length of incision, recovery time, and postoperative complications but no significant differences in preoperative and postoperative erythrocyte sedimentation rates and C-reactive protein values, kyphosis, and neurologic function, recovery of ability to live and work, and postoperative healing of bone grafts.Conclusion: The modified extradiaphragmatic thoracolumbar approach for anterior thoracolumbar spine surgery is as effective as the traditional approach. However, associated surgical trauma is minimal, and the incidence of pulmonary complications is low. [ABSTRACT FROM AUTHOR]

Purpose: To construct and validate a prediction instrument for early identification of patients with a high risk of delayed recovery after whiplash injuries (PPS-WAD) in an insurance company setting.Methods: Prospective cohort study. On the basis of a historic cohort (n = 130) of patients with a whiplash injury identified in an emergency room (ER, model-building set), we used logistic regression to construct an instrument consisting of two demographic variables (i.e. questions of educational level and work status) and the patient-rated physical and mental status during the acute phase to predict self-reported nonrecovery after 6 months. We evaluated the instrument's ability to predict nonrecovery in a new cohort (n = 204) of patients originating from an insurance company setting (IC, validation set).Results: The prediction instrument had low reproducibility when the setting was changed from the ER cohort to the IC cohort. The overall percentage of correct predictions of nonrecovery in the ER cohort was 78 % compared with 62 % in the IC cohort. The sensitivity and specificity in relation to nonrecovery were both 78 % in the ER cohort. The sensitivity and specificity in the insurance company setting was lower, 67 and 50 %.Conclusion: Clinical decision rules need validation before they are used in a new setting. An instrument consisting of four questions with an excellent possibility of identifying patients with a high risk of nonrecovery after a whiplash injury in the emergency room was not as useful in an insurance company setting. The importance and type of the risk factors for not recovering probably differ between the settings, as well as the individuals. [ABSTRACT FROM AUTHOR]

Objective: For three or more involved cervical levels, there is a debate over which approach yields the best outcomes for the treatment of multilevel cervical degenerative disease. Our objective is to compare the radiological and clinical outcomes of two treatments for multilevel cervical degenerative disease: anterior cervical discectomy and fusion (ACDF) versus plate-only open-door laminoplasty (laminoplasty).Methods: Patients were randomized on a 1:1 randomization schedule with 17 patients in the ACDF group and 17 patients in the laminoplasty group. Clinical outcomes were assessed by a visual analog scale (VAS), Japanese Orthopedic Association (JOA) scores, operative time, blood loss, rates of complications, drainage volume, discharge days after surgery, and complications. The cervical spine curvature index (CI) and range of motion (ROM) were assessed with radiographs.Results: The mean VAS score, the mean JOA score, and the rate of complications did not differ significantly between groups. The laminoplasty group had greater blood loss, a longer operative time, more drainage volume, and a longer hospital stay than the ACDF group. There were no significant differences in the CI and ROM between the two groups at baseline and at each follow-up time point. ROM in both groups decreased significantly after surgery.Conclusions: Both ACDF and laminoplasty are effective and safe treatments for multilevel cervical degenerative disease. ACDF causes fewer traumas than laminoplasty. [ABSTRACT FROM AUTHOR]