Objective To summarize the clinical features and diagnostic flow of cervical spondylosis with proximal upper extremity amyotrophy;and further analyze the clinical effect of cervical anterior decompression and fusion on cervical spondylosis with proximal upper extremity amyotrophy.Methods Twenty-two cases of cervical spondylosis with proximal upper extremity amyotrophy were analyzed retrospectively from June 2006 to December 2013.Seventeen males and 5 females with an average age of (55.73 ± 8.64) years (38 to 68 years) were included.The mean preoperative course of disease was (19.2 ± 21.86) months (1-72 months).Clinical symptoms,imaging findings and electrophysiological findings were analyzed.The muscular strength recovery of atrophic muscles was evaluated by Manual Muscle Testing (MMT).The clinical improvement rate was evaluated by the Japanese Orthopedic Association (JOA) score,and the clinical satisfaction was assessed at followed up.Results The muscles involved in patients of cervical spondylosis with proximal upper extremity amyotrophy are mainly the deltoid muscle,biceps and scapula levator muscle.Most cases of imaging findings showed multi-segmental degeneration,of which C4,5,C5,6 segments were most common.Neuroelectrophysiological examination showed that affected muscles experienced obvious denervation and decreased action potential.The average follow-up time was (44.14 ± 20.51) months (14 to 102 months).At the last follow-up,the JOA score (16.29 ±0.59) in 17 cases was higher than preoperative (15.12 ± 0.93),the difference was statistically significant (F=51.814,P=0.000),and the average improvement rate was 73.3％.MMT assessment showed that 19 patients (86.4％) in this group had muscle strength recovery for more than 1 grade at the last follow-up.The average clinical satisfaction was 83.7％.Conclusion The clinical diagnosis of cervical spondylosis with proximal upper extremity amyotrophy requires a combination of clinical symptoms,imaging findings and neurophysiological examination results for comprehensive judgment.Anterior cervical decompression and fusion in the treatment of cervical spondylosis with proximal upper extremity amyotrophy patients can achieve good clinical results.

Objective To investigate the risk factors and treatment strategy in treating adjacent segment diseases (ASD) after anterior cervical decompression and fusion.Methods Fourteen patients with ASD after anterior cervical decompression and fusion from December 2005 to August 2012 were analyzed.The overall curvature of the cervical spine,local curvature of surgical segments,and the distances between the plate and the upper and lower intervertebral space were measured and analyzed.10 males and 4 females,age at initial surgery was 36 to 68 years old,the mean was 52.0±11.0 years old.The secondary surgery was taken,according to the number of involved segments and other factors.Anterior decompression and fusion and internal fixation was taken to patients who segment number ≤2 without severe ossification of posterior longitudinal ligament or ossification of the ligamentum flava; posterior decompression and laminoplasty was conducted in patients whose segment number ≥3,but not accompanied with significant kyphosis,instability and serious ossification of the ligamentum flava; and posterior laminectomy and fusion was performed in patients with significant kyphosis,instability and not suitable for anterior decompression due to technical reasons,as well as patients with serious ossification of the ligamentum flava.Results The average time of occurrence of ASD after the initial surgery was 9.3±4.4 years,and the average age of reoperation was 61.3±12.4 years old.The overall curvature of the cervical spine,surgical segment local curvature after the initial surgical procedure were 12.4°± 10.8 o,1.5o±6.8o,respectively; and the distances between the plate and the upper and lower interyertebral space were:0.9± 1.8 mm,3.8±3.2 mm.The secondary surgeries were taken as follows:9 cases anterior decompression and fusion and internal fixation,3 cases posterior decompression and laminoplasty,and 2 cases posterior laminectomy and fusion.All 14 patients were followed up 30.4± 17.8 months,and the average improvement rate of Japanese Orthopaedic Association scores at the last follow up was 73.9％±9.7％.Conclusion The smaller distance between the plate and neighboring intervertebral space,and poorer local curvature of surgical segments might be the risk factors for ASD after anterior cervicad decompression and fusion.The appropriate secondary surgery was taken after comprehensive analysis of the number of adjacent segments,compression factors,cervical curvature and other factors.

Objective To investigate the clinical effect of different surgical approaches on multi-level cervical spondylosis in elderly patients.Methods A total of 53 aged patients with multi-level cervical spondylosis (≥70 years old) who received operation in our department during May 2007 to May 2014 were retrospectively studied, and divided into anterior cervical surgical group (n=22) and posterior cervical group (n=31), according to the surgical approach.The operation duration, intraoperative blood loss, hospitalization time, postoperative complications, Japanese orthopedics association (JOA) scores, Neck disability index (NDI), postoperative subjective improvement of clinical symptoms and spinal fusion of the two groups were evaluated and compared respectively.Results The mean operative time was longer in the anterior surgical group than in the posterior surgical group [(2.7±0.5)h vs.(1.9±0.3) h, P＜0.05].The average blood loss of the anterior surgical group was less than that of posterior surgical group [(90.0±50.4) ml vs.(160.7±40.5)ml, P＜0.05].The hospitalization time of the anterior surgical group was less than that of posterior surgical group [(10.3±2.5) d vs.(15.7±3.6) d, P＜0.05].Postoperative JOA score of anterior surgical group was higher than that of posterior surgical group 6 months after surgery [(14.7 ±0.8)vs.(13.8±1.2), P＜0.05], while there was no significant difference in JOA score between the two groups up to the last follow-up [(14.8±1.2) vs.(14.7±1.8), P＞0.05].NDI score was lower in anterior surgical group than in posterior surgical group 3, 6, 12 months after operation and at the last follow-up.Among the 41 patients, radiographic outcomes showed that there were 16 cases of anterior surgical group with no bony fusion at the follow-up 3 months after operation, and all the 16 patients achieved bony fusion at the follow-up 1 year after operation, and there were 4 cases with titanium mesh subsidence (＜ 3 mm).Conclusions Both anterior cervical decompression and fusion and posterior cervical single open-door laminoplasty have good efficacy in the treatment of multilevel cervical spondylosis in elderly patients, which have advantages on the limb functional recovery time and cervical function assessment.When anterior cervical surgical contraindications were excluded, the anterior cervical decompression and fusion may be a good choice for the treatment of multilevel cervical spondylosis in aged patients.

Objective To determine anatomic parameters related to the surgery of lumbar cortical bone trajectory of normal adults and the feasibility of screw application in cortical bone and its specification and dimension.Methods Lumbar 3D image data of 80 adults between 18 and 40 years old (40 for each gender) were randomly selected as subjects of our research.With the help of the imaging software for 3D interactive viewing,the ideal starting point was supposed to be the junction of the center of the superior articular process and 1 mm below the inferior border of the transverse process.The diameter,length,lateral angle to the vertebral horizontal plane,cephalad angle to the vertebral sagittal plane of the trajectory and the horizontal distance from the insertion point to the lateral edge of the vertebral plate were measured.Differences of anatomic parameters for each gender,side and segment were analyzed.Results Differences of anatomic parameters on both sides of each segment had no statistical significance.At the ideal trajectory,the mean screw length was 37.56±2.41 mm at L1,38.72±2.36 mm at L2,39.51 ±2.51 mm at L3,39.78± 2.87 mm at L4 and 38.83±2.74 mm at L5.The mean screw diameters from L1 to L5 were 6.04±1.23 mm,6.17±1.24 mm,7.15±1.22 mm,8.02± 1.41 mm and 8.68± 1.42 mm respectively.However,differences of ideal entry angle of L1 to L5 had no statistical significance.The mean lateral angle from L1 to L5 were 8.46°±2.11°,9.37°±2.84°,9.62°±2.16°,9.53°± 1.98°,9.04°± 1.97°,while the mean cephalad angle to the vertebral sagittal plane from L1 to L5 were 26.49°±4.97°,25.94°±4.56°,26.42°±4.42°,26.29°±3.48°,26.89°±3.69°.The mean distance from the insertion point to the lateral edge of the vertebral plate gradually increased from L1 to L5,which were 1.19±0.75 mm,1.54±1.08 mm,2.01±1.45 mm,3.49±1.52 mm,4.47±1.32 mm respectively.The screw diameters of each segment for men were greater than those for women.Conclusion The common length of screw for lumbar cortical bone trajectory of normal adults might be from 35 mm to 40 mm.The safe upper limits of the screw diameter were 5.5 mm at L1,5.5-6.0 mm at L2,6.5-7.0 mm at L3,7.5 mm at L4 and 8 mm at L5.The average lateral angle of all 5 lumbar segments was 9.20°± 2.11° and the average cephalad angle was about 26.41°±4.22°.

Objective: To investigate the effect of modified transforaminal lumbar interbody fusion (TLIF) on coronal degenerative lumbar scoliosis (DLS) in adults with mild Drum Tower Hospital Classification type B and C coronal imbalance. Methods: From January 2011 to December 2015, 31 patients with mild coronal imbalance underwent long-segment fusion for DLS, 27 females and 4 males, with an average age of 63.1±5.5 years (52-76 years), were retrospectively analyzed. According to the coronal balance classification of Drum Tower degenerative scoliosis, there were 20 patients with type B and 11 patients with type C. The average follow-up time was 38.5±9.3 months. Sagittal parameters includingpelvic tilt (PT), PI-LL (pelvic incidence, PI; lumbar lordosis, LL), sagittal vertical axis (SVA) and coronal parameters includingCobb angle, coronal balance distance (CBD), lumbosacral inclination angle (when L ₅ is the lower fusion vertebra, the angle between L₄ upper endplate and horizontal line was measured; when S₁ or S₂ was the lower fusion vertebra, the angle between L ₅ upper endplate and horizontal line is measured), and clinical scores including Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) (excluding sexual life assessment)were recorded before and during the last follow-up. Complications such as internal fixation displacement, fracture and loss of correction were evaluated at the last follow-up. The main method of surgical correction was the modified TLIF operation on the distal compensatory curve and concave side. After the soft tissue is released, the ipsilateral intervertebral fusion cage was implanted to distract the intervertebral space. SPSS 20.0 was used for statistical analysis. All data were expressed as mean ±standard deviation. Paired t-test was used to evaluate the imaging measurement and clinical scores. Independent sample t-test was used to compare the databetween type B and C. P value less than 0.05 has statistical significance. Results: The mean operating time was 4.4±0.9 h (3.1-6.0 h) and the mean intraoperative bleeding was 777±249 ml (500-1 300 ml). For Sagittal balance, PI-LL was 21.7°±5.3° in 31 patients before operation, and the last follow-up was 7.4°±2.4° (t=16.41, P<0.001); PT was 32.6°±7.6° before operation, and the last follow-up was 24.1°±8.5° (t=15.32, P<0.001); SVA was 52.2±16.2 mm before operation, and the last follow-up was 25.5±13.8 mm (t=10.20, P<0.001). For coronal balance, the lumbosacral tilt angle was 8.8°±3.4°, and the last follow-up was 3.9°±2.1°. The average correction rate was 56.0%. The preoperative scoliosis Cobb angle was 41.5°±9.6°, and the last follow-up was 19.7°±6.7° (t=17.90, P <0.001). The average correction rate was 52.7%. The preoperative CBD was 4.3 ±0.7 mm, and last follow-up was 1.6 ± 0.8 mm (t=33.76, P < 0.001). In terms of clinical scores, the VAS score of 31 patients before operation was 6.5±1.0, and the last follow-up was 2.7±1.0 (t=15.97, P <0.001); the ODI score before operation was 34.8%+5.6%, and the last follow-up was 18.0%±5.4% (t=12.42, P <0.001). There were no significant differences in sagittal parameters, coronal parameters and clinical efficacy scores between group B and group C. Conclusion In adult DLS patients with mild coronal B-type and C-type imbalances, the application of modified TLIF interbody fusion and cage insertion in the distal convex side of lumbar scoliosis can achieve the levelization of lumbosacral region and correct coronal imbalance.

Objective: To summarize the clinical features of cervical spondylosis with distal upper extremity amyotrophy; and further analyze the clinical efficacy of cervical anterior decompression and fusion on cervical spondylosis with distal upper extremity amyotrophy. Methods: Thirty cases of cervical spondylosis with distal upper extremity amyotrophy were analyzed retrospectively from June 2006 to June 2015. nineteen males and eleven females with an average age of 55.20±9.08 years (41 to 72 years) were included. The preoperative course was 1 to 108 months with a median of 6 months. The muscle extent of the affected group, the segmentation and location of spinal canal stenosis, and the results of neurophysiological examination were analyzed. The muscular strength recovery of atrophic muscles was evaluated by Manual Muscle Testing (MMT), and the clinical satisfaction was assessed at the last followed up. Results: The muscles involved in patients of cervical spondylosis with distal upper extremity amyotrophy are mainly the thenar muscle (17 cases, 56.7%), interosseous muscle (15 cases, 50.0%), and shypothenar muscles (13 cases, 43.3%). Most cases of imaging findings showed multi-segmental degeneration, of which C_{5, 6} (24 cases, 80.0%), C_6,7 (21 cases, 70.0%) segments were most common, and the types of anterior compression: 23 segments (33.5%) of the central type, 37 segments (54.4%) of the lateral-central type, and 8 segments (11.8%) of the foramen type. Neuroelectrophysiological examination showed that cervical spinal cord anterior horn cells or nerve root damage, the most commonly involved segments of C₇, C₈, T₁(18 cases, 60.0%). The average follow-up time was 36.8 months. At the last follow-up, MMT assessment showed that thirteen patients (43.3%) in this group had muscle strength recovery for more than one grade at the last follow-up. The average clinical satisfaction was 73.4%. Conclusion The clinical diagnosis of cervical spondylosis with distal upper extremity amyotrophy requires a combination of clinical symptoms, imaging findings and neurophysiological examination results for comprehensive judgment. Cervical anterior decompression and fusion can effectively prevent the progression of cervical spondylosis in distal upper extremity amyotrophy patients, and some patients can get a good muscle recovery.

Methods: Preoperatively, all 160 patients with OVCFs underwent pressure-pain threshold (PPT), temporal summation (TS), conditioned pain modulation (CPM), and imaging assessments. Pain intensity and pain-related disability were evaluated before and after PVP. Results: Preoperatively, patients with OVCFs had lower PPTs in both local pain and pain-free areas and lower CPM and higher TS in pain-free areas than healthy participants (p<0.05). Unlike patients with acute fractures, patients with subacute/chronic OVCFs showed higher TS with or without lower CPM in the pain-free area compared with healthy participants (p<0.05). Postoperatively, RBP occurred in 17 of 160 patients (10.6%). All preoperative covariates with significant differences between the RBP and non-RBP groups were subjected to multivariate logistic regression, showing that intravertebral vacuum cleft, posterior fascia edema, numeric rating pain scale scores for low back pain at rest, and TS were independently associated with RBP (p<0.05). Conclusions Augmented central pain processing may occur in patients with OVCFs, even in the subacute stage, and this preexisting CS may be associated with RBP. Preoperative assessment of TS in pain-free areas may provide additional information for identifying patients who may be at risk of RBP development, which may be beneficial for preventing this complication.

OBJECTIVETo identify whether there is significant changes between the cervical neutral F-waves and cervical flexion F-waves in the patients with Hirayama disease.

METHODSThis study was performed on 25 normal subjects and 22 male patients with identified Hirayama disease (age: 15 to 44 years; height: 165 to 183 cm; duration: 6 to 240 months) between May 2010 and March 2014. Both cervical flexion F-wave (cervical flexion 45 °, 30 minutes) and conventional F-waves to median nerve stimulation and to ulnar nerve stimulation were performed in all subjects bilaterally.

RESULTSwere analyzed by t-test or Fisher exact probability.

RESULTSIn the normal subjects, all measurements of the bilateral F-waves didn't have any difference between the cervical flexion position and the cervical neutral position. On the cervical neutral position, the persistence (t = 5.209, P = 0.000), average latencies (t = 4.731, P = 0.022) and minimal latencies (t = 23.843, P = 0.006) of ulnar F-wave on the symptomatic heavier side from the patients with identified Hirayama disease were significantly lower or longer than those from the normal subjects, and the repeat F-waves were found in 3 patients (13.6%). On the symptomatic lighter side, the ulnar F-waves only had lower persistence (t = 22.306, P = 0.001) along with 5 repeat F-waves. Only lower persistence were found in the median F-wave on the both side (higher side t = 23.696, P = 0.000; lighter side t = 23.998, P = 0.000), along with 5 (22.7%) repeat F-waves on the symptomatic heavier side and 6 (27.3%) ones on the symptomatic lighter side. After cervical flexion maintaining 30 minutes, the increased maximal amplitudes (t = -2.552, P = 0.019), average amplitudes (t = -3.322, P = 0.003), duration (t = -3.323, P = 0.00), persistence (t = -2.604, P = 0.017) and frequency of repeat F-waves (9/22, 41%) (P = 0.044) were found on the symptomatic heavier side of ulnar F-wave, and 5 of 10 absent ulnar F-wave on the cervical neutral position were also recover. The median F-wave on the symptomatic heavier side mainly had increased maximal amplitude (t = -3.847, P = 0.001), average amplitudes (t = -2.188, P = 0.040) and persistence (t = -2.421, P = 0.025), and 1 of 6 absent median F-wave on the cervical neutral position were also recover after cervical flexion.

CONCLUSIONThe cervical flexion F-waves have significant regular changes compared to the cervical neutral F-waves in patients with Hirayama diseases, especially maximal and average amplitudes of F-waves.

Adolescent ; Adult ; Humans ; Male ; Neck ; Range of Motion, Articular ; Spinal Muscular Atrophies of Childhood ; physiopathology ; Ulnar Nerve ; Young Adult

Objective To investigate the mechanisms of sacroiliac joint pain after lumbar fusion surgery and to present the clinical outcomes after a combining intra-and peri-articular injection.Methods Totally 20 male and 15 female patients (48-75 years old) from January 2013 to December 2016 were retrospectively included in the present study.The patients were all with sustained low back and hip pain after prior posterior lumbar interbody fusion surgery.Nine cases were diagnosed with lumbar disc herniation,22 cases with lumbar stenosis,and 4 cases with degenerative lumbar spondylolisthesis.Ten cases were performed with single level fusion,16 cases with two level fusion,9 cases with 3 or more level fusion.Autogenous iliac bone graft was not applied in any of those patients.The pain of the patients was confirmed from the sacroiliac joint through specific symptoms and signs.They were divided into two groups and were treated with either standard intra-articular injection (17 cases) or a combine of intra-and peri-articular sacroiliac injection (18 cases).Peri-articular injection was conducted at 1 cm above the inferior margin of the sacroiliac joint.Recover ratios of visual analogue scale (VAS) and Oswestry disability index (ODI) at 2 weeks post-operatively were recorded and were compared between the two groups.Results No statistical difference was found in gender,fusion location,fusion levels,pre-operative VAS and ODI score between the two groups (P ＞ 0.05).The combination of intra-and peri-articular sacroiliac injection showed significantly better results than the single intra-articular injection in VAS score immediately after injection (t=2.159,P=0.038),VAS score at 2 weeks after injection and ODI score at 2 weeks after the injection (t=2.705,P=0.011;t=2.156,P=0.039,respectively).Conclusion Both intra-and extra-sacroiliac joint diseases may lead to sacroiliac joint pain after lumbar fusion surgery.A single intra-articular sacroiliac injection could not provide optimistic outcomes.Further extra-articular injection is required at approximate 1 cm above the inferior margin of the sacroiliac joint.The technique combining intra-and peri-articular injection could guarantee improved early clinical outcomes.

Objectives: To study the relationship between the anatomical parameters of transverse foramen and intervertebral discs in the cross-section of the cervical spine in healthy adults, and to evaluate the risk of vertebral artery injury in the anterior cervical spine surgery. Methods: There were 24 healthy adults(12 male, 12 female) underwent neck CT angiography with clear vertebral artery and the adjacent structure imaging from June to December 2014 in Huashan Hospital, Fudan University. The anatomical parameters of vertebral artery V2 segment with lower cervical vertebrae and intervertebral discs were measured by cross-sectional images of C_3-6. The corresponding parameters of different sex and both sides of the same segment were analyzed by independent samples t-test and paired t test, respectively. The least significant difference(LSD) t test was used to compare the corresponding data between different segments. Results: The vertebral artery was not walking in the middle of the transverse foramen in healthy individual, but partial medial, partial front walking. Transverse diameter of transverse foramen in male and female were 6.62-6.89 mm and 6.21-6.45 mm, and sagittal diameter was 5.41-6.48 mm and 5.40-6.10 mm, respectively.The transverse foramen were slightly oval. The distance between vertebral artery and midline in male and female were 14.23-16.12 mm and 13.60-15.04 mm, respectively, which was much larger than the width of cervical vertebral corpectomy. Compared with C_3-4, intervertebral disc, the transverse distance between the vertebral artery and the uncovertebral joint of C_4-5, C_5-6 was smaller, and the distance from the vertebral artery to the posterior margin of the uncovertebral joint was relatively small, the difference was statistically significant (t=2.449, P=0.022). The distance from vertebral artery to the posterior margin of uncinate process was 1/5-2/5 of the distance between the anterior and posterior edge of the corresponding segmental vertebra. Conclusion Based on this anatomical study, the risk of vertebral artery injury in conventional anterior cervical decompression is small, and the risk of vertebral artery injury in different segments is slightly different.