Objective:To compare the technique between concave distraction and convex resection in the treatment of congenital cervicothoracic scoliosis and evaluate its curative effect.Methods:Data of congenital cervicothoracic scoliosis patients from January 2010 to January 2020 were collected, among which 5 were males and 3 were females. The patients' age was 12.5±4.5 years old (range 6-20 years old). One case had C 7 wedged vertebra, 4 cases had T 1 hemivertebra and unbalanced vertebra, 2 cases had T 2 hemivertebra and 1 case had fused facet joint and wedged lamina in T 1. All patients had different degrees of vertebra fusion. Convex resection technique (one stage anterior and posterior combined hemivertebrae resection and annular osteotomy) was used to treat 4 cases before 2015; Concave distraction technique (A combination of anterior and posterior release, intervertebral space and facet space distraction, cage placed and fusion) was used to treat 4 cases after 2015 and 2 of them had 2 segments distraction. Perioperative neurological, vascular and wound related complications were recorded. The main parameters were structure Cobb angle, cephalic and caudal compensatory Cobb angle, mandibular incline, neck tilt, shoulder balance and head shift were measured pre-operation, post-operation and at the last follow-up. Results:All patients' surgeries were completed successfully. In convex resection group, the duration of surgery was 201±100 min (range 113-300 min) per vertebra, the estimated blood loss was 294±153 ml (range 100-450 ml) per vertebra, the hospital stay was 14±3 d (range 11-18 d) and follow up time was 51±11 months (range 36-60 months). In concave distraction group, the duration of surgery was 117±14 min (range 101-129 min) per vertebra, the estimated blood loss was 119±36 ml (range 85-167 ml) per vertebra, hospital stay was 17±3 d (range 14-20 d) and follow up time was 28±21 months (range 12-60 months). Convex resection group had longer operation time and more blood loss per vertebra than concave distraction group. In convex resection group, structural Cobb angle was 45.1°±21.0° pre-operation and 22.7°±15.3° post-operation, which was corrected significantly ( Z=6.53, P=0.038). The correction rate was 54.8%±30.9%. Cephalic compensatory Cobb angle was 22.1°±8.2° pre-operation and 8.2°±5.8° post-operation, which was corrected significantly ( F=6.01, P=0.049). The correction rate was 66.8%±15.1%. Mandible incline was 7.8°±3.1° pre-operation and 3.5°±1.5° post-operation, which was corrected significantly ( F=8.02, P=0.018). The correction rate was 51.0%±29.7%. In concave distraction group, structural Cobb angle was 32.2°±27.2° pre-operation and 16.3°±16.7° post-operation, which was corrected significantly ( F=7.43, P=0.024) . The correction rate was 59.0%±24.7%. Caudal compensatory Cobb angle was 18.9°(17.2°, 32.1°) pre-operation and 9.5°±10.3° post-operation, which was corrected significantly ( Z=6.00, P=0.049). The correction rate was 64.0%±24.1%. Clavicle angle was 3.9°±2.3° pre-operation and 0.3°±0.4° post-operation, which was corrected significantly ( F=1.75, P=0.040). The correction rate was 97.0% (48.5%, 99.8%). There was no significant difference in the correction rate of all radiographic parameters between the two groups. At the last follow-up, the patients' appearance of head, neck and shoulder were improved compared with those before surgery. In convex resection group, 2 patients showed nerve root stimulation symptoms postoperatively on convex side. One patient developed C 5 nerve root palsy which weakened deltoid muscle and the other patients presented with reduced triceps muscle strength. In concave distraction group, one patient developed C 5 nerve root palsy on convex side. All these symptoms recovered by conservative treatment 3 months after operation. Conclusion:It is safe and effective to treat congenital cervicothoracic scoliosis with convex resection technique and concave distraction technique. The concave distraction technique has the advantages of more safety, less operating time, less blood loss and easier to perform and has a wider application prospect.

Objective:To explore the safety, feasibility, and short-term outcome ofdistraction on the concave side in the treatment of patients with congenital cervical scoliosis.Methods:Between August 2015 and December 2019, 11 patients with congenital cervical scoliosis underwent distraction technique on concave side, among which 5 were males and 6 were females. Age was 9.9±3.1 years old (range 6-16 years old). The primary cervical spine deformity was hemi-vertebra with different degrees of vertebra fusion. 7 cases were in C 3, 3 cases were in C 4 and 1 case was in C 5. Anterior-posterior combined approach was used. Firstly, discectomy and soft tissue release on concave side were made through anterior approach, then distraction on concave side and fusion with internal fixation were made through posterior approach and at last fixation and fusion in anterior approach were made. In this study we measured structure Cobb angle, compensatory Cobb angle, mandibular incline, shoulder balance and the angle difference of trapezius muscle preoperation and post operation. Perioperative neurological,vascular and wound related complicationswere recorded. Results:All patients' surgeries were completed successfully. Eight patients received single site distraction and 3 patients received distraction in two sites. The duration of surgery was 466±141 min (range 150-659 min), the estimated blood losswas 387±191 ml (range 100-660 ml) and follow up time was 12.2±9.5 months (range 3-24 months). Structural Cobb angle was 28.9°±13.1° pre-operation and 7.4°(3.0°, 27.7°) post-operation at 3 months, which was corrected significantly ( Z=-2.934, P=0.003). The correction rate was 58.1±26.1% (range 18.8%-97.6%). Structural Cobb angle was 13.2°±12.3°at 1 year post operation and had no significant difference compared with 3 months post operation ( t=1.960, P=0.107). Compensatory Cobb angle was 18.3°±6.1° pre-operation and 9.4°±7.3° post-operation at 3 months, which was corrected significantly ( t= 5.071, P<0.001) and the correction rate was 51.3%±28.3% (range 2.4%-94.7%). Compensatory Cobb angle was 8.9°±7.7° at 1 year follow up and was corrected significantly ( t=5.253, P=0.003) compared to 3 months after surgery and the correction rate was 61.4%±26.9%. Two patients developed C 5 nerve root dysfunction and 1 patient developed numbness on the index and middle fingers after surgery. All of them occurred on the concave side and recovered by conservative treatment. Conclusion:The application of distraction on the concave side in the treatment of congenitalcervical scoliosis is with good feasibility and clinical safety. Short-term follow-up showed excellent resultswith a promising future.

Objective To quantitatively compare the effect of preservation or removal of atlas posterior arch on cervical posterior decompression,so as to provide a basis for reasonable selection of upper cervical spine decompression range and determination of surgical indications for atlas posterior arch resection.Methods The data of 45 patients with posterior decompression of upper cervical spine were retrospectively analyzed.According to the decompression range,the patients were divided into C2-C7 group and C1-C7 group.There were 25 cases in the C2-C7 group,19 males and 6 females,with an average age of 56.3 years (40-71 years),4 cases of cervical spondylotic myelopathy and 21 cases of ossification of the posterior longitudinal ligament of cervical spine.All of the 25 patients underwent open-door laminoplasty:20 cases with hinge side anchoring procedure and 5 cases with preservation of the unilateral posterior muscular-ligament complex procedure (titanium cable procedure).There were 20 cases in C1-C7 group,12 males and 8 females,with an average age of 58A years (44-75 years).All of the 20 cases underwent atlas posterior arch resection as well as C2-C7 open-door laminoplasty,including anchoring procedure in 1 case,titanium miniplate procedure in 4 cases,and titanium cable procedure in 15 cases.Standardized vertebral-cord distance (SVCD) at each level from atlas to level C~ was measured on T2-weighted images of MR on the mid-sagittal plane in the neutral position pedormed 3-12 months postoperatively at each individual level.As the main outcomes,the SVCD values obtained at the same level of the two groups were compared between the two groups.Shapiro-Wilk normality test was performed on the SVCD values at C1.2 and C2 levels of two groups.The area under the normal distribution curve of SVCDs was used to calculate the corresponding residual compression rate with different magnitude of compression mass to further discover the difference of the decompression effect between the two groups.Results The SVCD obtained at the level of the anterior arch of atlas (C1),the junction of odontoid process and axis (C1,2) and the middle part of axis body (C2) in the C2-C7 group was 9.91±1.34 mm,8.35±1.27 mm,and 8.22 ±1.43 mm,respectively.The SVCD at the same levels was 11.02±1.60 mm,9.72±1.24 mm,and 9.12±1.11 mm,respectively.SVCDs differed significantly in the above range between the two groups.However,from level C2,3 to C6,7,there was no significant difference in SVCDs between the two groups.The JOA score of group C2-C7 was 11.8±2.7 preoperatively and increased significantly to 14.7±1.8 at 12 months postoperatively(t=-7.006,P＜0.001) with a recovery rate of 57.0％±32.2％.The JOA score of group C1-C7 was 11.7±2.8 preoperatively and increased significantly to 14.2±2.3 at 12 months postoperatively(t=-6.177,P＜0.001) with a recovery rate of 51.9％±32.1％.Conclusion Atlas posterior arch resection can significantly increase the decompression effect of posterior cervical surgery from the anterior arch of atlas to the middle part of axis body,but it would not increase the decompression effect at level C2.3 or below.When the magnitude of the ventral compression factor exceeds the decompression limit (8.5 mm) available with C2-C7 decompression in the range from atlas to the middle of the axis body,extending the decompression range by atlas posterior arch resection is an effective means to achieve adequate decompression.

Objective　To assess the mid-term clinical and radiological outcomes of anterior cervical internal fixation and fusion for the treatment of Hirayama disease and to evaluate the clinical significance and value of this procedure.Methods　All of 31 patients underwent anterior cervical internal fixation and fusion were retrospectively analyzed with a minimum of 5 years follow-up in our hospital between May 2008 and May 2011,whose disease progressively deteriorated after six-month's conservative therapy(neck collar)preoperatively.There were 30 males and 1 female with an average age of 19.0±2.7 years which ranged from 16 to 27.The clinical outcomes included forearm and hand muscle atrophy and strength.The radiological outcomes included range of motion(ROM)of the whole cervical spine and unstable segments,as well as venous flow empty phenomena and "snake eyes" sign on MRI in the flexed position.All were recorded at 3 month,1 year,3 year and 5-6 years follow-up time points after surgery.The preoperative and postoperative quantitative variables were analyzed by paired t test,and a P<0.05 was used to indicate statistical significance.Results　All the patients showed no further progression of symptoms of muscular weakness or atrophy.At the end of 5-6 years follow-up,24 of the 31 patients(77.4%)showed improved muscle strength and 16 of the 31 patients(51.6%)showed improved atrophy.Thirty-one patients had a forearm muscle strength of 4 to 5 at the last follow-up,with an average of 4.9±0.3,which was superior to preoperative 0 to 5(3.6±1.0);grip strength was 3 to 5 kg,with an average of 3.9±0.7 kg,significanthigher than 1 to 3.8 kg(2.5±0.8 kg)before surgery.Score of muscle strength of the 31 patients at the end of 5-6 years' follow-up was 4.9±0.3(4 to 5),which was significantly higher than preoperative.Postoperative X-rays at the end of 5-6 years' follow-up revealed that all the cases' internal fixation was at the proper position,and no losing or broken of the internal fixation were identified.Dynamic X-rays of cervical spine showed the range of motion(ROM)of the whole cervical spine was significantly decreased after the operation.The ROM of preoperation was 77.8o±12.70 and that of 5—6 years postoperation was 27.90±7.60.The unstable segments of cervical spine became stable postoperatively.The flexible position MRI of cervical spine showed the spinal cord was completely relieved,without new compression.Venous flow empty phenomena disappeared and no "snake eyes" sign was identified.Conclusion　Anterior cervical internal fixation and fusion is an effective surgical treatment for Hirayama disease and may provide preferable mid-term clinical and radiological outcomes.This procedure has clinical significance and value in terms of control of the progression and outcome of this disease.

Objective　To investigate the clinical efficacy of anterior cervical surgery by comparative analyzing hand dysfunction using brief Michigan hand questionnaire(Brief MHQ)in Hirayama disease patients.Methods　From Aug 2011 to Dec 2016,27 patients of hirayama disease who underwent surgery were enrolled in this study.The study group consisted of 27 men.The mean follow-up period was 41.1 months.The levels of surgery included 18 cases of C4-C7,6 cases of C3-C6,2 cases of C4-C6 and 1 case of C5-T1.Brief MHQ were evaluated for the 27 patients.According to the Wilcoxon analysis,the unchanged domains were analyzed with the multifactor Logistic regression analysis by preoperative duration of symptoms,age of onset,and number of affected extremities.Dynamic flexion-extension lateral X-rays were performed at baseline and at final follow-up.Results　No failure of internal fixation was detected on dynamic flexion-extension lateral X-rays.Five domains of preoperative Brief MHQ had lower scores,including Function,Satisfaction,Aesthetics,Activities of daily living,Work domain.With the exception of Aesthetics and Pain domain,all the other four domains showed significant improvement after surgery.The total score was 38.44±5.83 at base-line and 43.19±4.47 at follow-up.The score of Function was 5.19±1.36 at baseline 6.37±1.15 at follow-up;The score of Satisfaction was 5.56±1.22 at baseline 6.60±1.05 at follow-up;The score of Activities of daily living was 6.33±1.84 at baseline 7.60±1.47 at follow-up;The score of Work was 6.85±1.75 at baseline 7.67±1.33 at follow-up.The risk factors of postoperative outcomes reported in the literature included duration of disease at the time of surgery,age of onset,and extremity involvement.According to the Logistic regression,pre-operation duration was the risk factor for Aesthetics domain and the cut-off time was 1.75 years.Conclusion　Four domains of Brief MHQ score were improved significantly after anterior surgery for patients with hirayama disease.Brief MHQ was useful to evaluate the hand dysfunction and clinical efficacy in patients with hirayama disease.

Objective　To investigate the relationship of motor unit number estimation(MUNE)by multiple point stimulation with the outcome of surgical treatment patients with Hirayama disease(HD).Methods　A total of 36 consecutive patients including unilateral in 26 cases and bilateral in 10 cases with Hirayama disease treated by anterior cervical discectomy decompression and fusion in Peking University Third Hospital from October 2007 to May 2015 were reviewed retrospectively.There were 35 males and 1 female,aged from 16-26 years(average,19.2 years).A total of 46 hands were enrolled.Odom criteria was used to evaluate the subjective outcome of surgical treatment.Multiple point stimulating technique was used to estimate the motor unit number of abductor pollicis brevis and abductor digitiminimi preoperatively and at the time of pre-operation and the latest follow-up.Hands were divided into two groups based on Odom criteria(Group A with excellent and good;Group B with fair and poor).The difference between the two groups were examined by t text.Results　A total of 46 hands with complete clinical and electrophysiology data were followed up for 12-96 months(average,28.2 months).The outcome at the final follow-up according to Odom criteria was:Excellent in 8 cases,Good in 18 cases,Fair in 20 cases and no Poor case.MUNE of abductor pollicis brevis increased significantly after surgery from 139.6±68.4 to 188.2±60.4(t=-5.86,P<0.001).MUNE of abductor digitiminimi increased significantly after surgery from 75.0±66.3 to 104.2±80.4 significantly(t=-3.86,P<0.001).For two groups in age,follow-up period,preoperative MUNE of abductor pollicis brevis,and preoperative abductor digitiminimi,there was no significant difference.The illness course of Group A was 24.0±11.3 months,which was significantly shorter than Group B 34.9±21.2 months(t=-4.452,P<0.01).Group A had more increased MUNE of abductor pollicis brevis 65.6±64.1 compared with Group B 26.7±34.7(t=2.446,P<0.05)and Group A had more increased MUNE of abductor digitiminimi 42.6±59.3 compared with Group B 11.8±32.4 after surgery(t=2.088,P<0.05).Conclusion　MUNE by multiple point stimulating technique could be used to evaluate the neurological function of Hirayama disease and the outcome of surgical treatment quantitatively.

Objective To investigate whether the hyperintensity on T2?weighted MRI affects the outcome of cervical ar?throplasty (CA) for cervical spondylotic myelopathy (CSM). Methods 69 patients with CSM who had undergone CA between June 2005 and December 2007 were retrospectively reviewed. They were divided into three groups according to the intensity of T2?weighted images:Group A, whose intensity of T2?weighted images in spinal cord compression spot was equisignal;Group B, hyper?intensity with obscure border; Group C, hyperintensity with clear border. There were 22 males and 19 females in group A aged from 27 to 63 years old, whose duration of disease was between 3 to 72 months, and there were 34 single?segment cases, 5 double?segment and 2 triple?segment cases. There were 9 males and 9 females in group B aged from 30 to 61 years old whose duration of disease was between 3 to 24 months, and there were 12 single?segment and 6 double?segment cases. There were 4 males and 6 fe?males in group C aged from 28 to 56 years old whose duration of disease was between 1 to 24 months, and there were 8 single?seg?ment and 2 double?segment cases. Two types of artificial cervical disc were used:Bryan Disc in 42 cases and Prodisc?C in 44 cas?es. The duration of Group A (24.7 ± 27.9 months) was significantly longer than that in Group B (6.6 ± 7.4 months) and Group C (11.1±9.5 months). The follow?up period was from 48 to 86 months with an average time of 61 months. The preoperative X?ray and MR as well as postoperative X?ray were collected. The history, compress ratio of MRI, the ROM of cervical segments pre and post?operatively were recorded and Japanese Orthopaedic Association (JOA) was used to evaluate the neurological function. Results Preoperative compress ratio of MRI were 43.3%± 15.2%, 42.4%± 10.7%and 41.9%± 14.8%respectively;preoperative segmental ROM were 9.6°±2.5°, 9.0°±1.7° and 9.1°±1.9° respectively. Preoperative JOA score were 13.6±1.2, 13.1±1.3 and 12.9±1.8, re?spectively. Postoperative JOA score at the latest follow?up were 16.2±1.0, 15.8±1.2 and 15.7±1.6 respectively. There was no statis?tic difference among these groups. Preoperative increased signal intensify on T2?weighted MRI in patients with cervical spondylot?ic myelopathy may not affect the outcome of cervical arthroplasty.

Objective To survey the current clinical practice of chronic non-cancer pain (CNCP)management including opioid use in Chinese subgroup report of Current Practices of Cancer and Chronic Non-Cancer Pain Management:A Pan-Asian Study (ACHEON).Methods This questionnaire-based survey included 100 pain physicians and 250 patients experiencing CNCP in the period of September to December in 2013.Results CNCP management training was believed by 40％ of physicians,while 30％ reported adequate pain-relief training on opioid use.Opioids were not considered as the best choice for CNCP management by 65％ of physicians.The majority of location of pain with CNCP was legs/feet (59.2％) and neck (39.2％),arthritis (37.22％),overuse (26.91％),and poor posture (35.56％) were reported as the primary causes of pain.A portion (81.6％) of patients was under treatment,while 66.67％ of patients claimed to be satisfied with their current pain treatment.74.51％ of patients reported that CNCP management was effective pain-relief.Conclusions The Chinese physicians were insufficient cognition of CNCP management on opioid use.The CNCP education and cognition strengthening,CNCP management practice and patient's satisfaction are still necessary for Chinese physicians and patients.

Objective:To retrospectively analyze the clinical data of the patients with reoperation for cervical myelopathy due to progressing ossification of the posterior longitudinal ligaments,with previous open-door expansive laminoplasty,and to evaluate the outcomes.Methods:From May 2006 to July 2012,a retrospective study was performed on a consecutive series of 17 patients with previous open-door expansive laminoplasty,who had received the reoperation for cervical myelopathy due to progressing ossi-fication of the posterior longitudinal ligaments.The reoperation was performed based on the clinical mani-festations and segments of responsibility.The anterior approaches were performed in 12 cases,and the posterior approaches in 5 cases.The correlation between the clinical factors and Japanese Orthopedic As-sociation (JOA)scores or the JOA recovery rate was evaluated by Pearson or Spearman correlation test. The pre-and post-operative JOA scores were analyzed by repeated measures ANOVA and the JOA recovery rates were compared with paired t test.Results:The mean follow-up was 137.5 months (range 60-348 months).There were no serious complications after surgical procedures.There was one case that had C5 palsy in the first operation and had recovery after one week.Another case had C5 palsy in the reoperation with posterior approach,which had recovery at the end of 6 months post-operation.Three cases had the cerebrospinal fluid leakage of the reoperation,with two cases in the anterior approaches and one case in the posterior approach.There was no significant correlation between the clinical variables and JOA scores or JOA recovery rates.The JOA scores of the patients in the first operation were improved from 9.4 ±4.1 to 12.8 ±2.8 (P<0.01),and the JOA recovery rate was 45.6%.The JOA scores of the reoperation were improved from 10.2 ±2.8 to 12.7 ±2.4 (P<0.05)at the end of 6 months and 14.3 ±1.9 (P<0.01)by the last follow-up.There were significant differences between the JOA recovery rates by the last follow-up (63 .2%)and at the end of 6 months (39 .3%)of the reoperation or 45 .6%of the first opera-tion (P<0.01).Conclusion:The reoperation for cervical myelopathy duo to progressing ossification of the posterior longitudinal ligaments can significantly promote the recovery of the spinal cord,based on the clinical manifestations combined with segments of responsibility of the imaging.

Objective To analysis the correlation between patient selection and heterotopic ossification (HO) after cervical artificial disc replacement.Methods Data of 48 patients with cervical spondylosis (34 cervical spondylotic myelopathy and 14 nerve-root type) who had undergone Bryan cervicadisc replacement from December 2003 to December 2008 were reviewed retrospectively,and all the patients had been followed up for more than 5 years.There were 21 males and 27 females with an average age of 42 years old (range,20-53 years).There were 38 single level replacement (C3-4 3 cases,C4-5 5 cases,C5-6 28 cases,C6-7 2 cases),9 double level replacement (C4-5,C5 6 4 cases;C5-6,C6-7 5 cases) and 1 three level replacement (C3-4,C4 5,C5-6) as a total of 59 surgical segments.The occurrence of HO was defined by McAfee classification on cervical lateral X-ray.Four factors were used in patient selection including gender,range of motion (ROM) of the target level,alignment of the functional spine unit (FSU) of the index level,and the disc height ratio between surgical level and the adjacent levels.The correlation between these four factors and HO was evaluated by logistic regression.The receiver operating characteristic (ROC) curve and area under the ROC curve were used to evaluate the significant result of logistic regression and the optimal diagnostic value.Results 48 patients were all followed up for an average period of 70.3 months (range,60-120 months).The occurrence rate in this study was 33.9％ (20/59 segments).Only one factor,the disc height ratio of the target level and its adjacent levels,presented statistical correlation with HO.ROC analysis showed that the area under the ROC curve of disc height ratio was 0.813 and the optimal diagnostic threshold was 0.9.Conclusion The disc height ratio of the target level and adjacent levels was the only patient selective factor correlated with the occurrence of HO.For those with disc height loss exceeding 10％ comparing to adjacent levels,it is not indicated for cervical artificial disc replacement with Bryan prosthesis.