Objective Maintaining the occipito-axial (O–C2) angle following occipitocervical fusion is crucial to prevent postoperative complications. Although automated O–C2 measurement has been reported, practical methods that provide rapid results for routine practice remain limited. This study aimed to develop a deep learning model using the YOLO (You Only Look Once) object detection algorithm to automatically identify anatomical landmarks and rapidly calculate the O–C2 angle.
Methods A retrospective analysis was conducted using cervical spine radiographs from 2 independent facilities. The internal dataset comprised 574 lateral cervical radiographs from 271 patients for model development, while the external validation dataset included 100 radiographs from 100 patients. Model performance was evaluated against manual measurements by 3 expert raters.
Results The model demonstrated excellent detection performance, achieving perfect metrics for the hard palate (F1 score: 1.00) and high performance for the occipital bone (F1 score: 0.97), anteroinferior corner of C2 (F1 score: 0.99), and posteroinferior corner of C2 (F1 score: 0.99). For O–C2 angle estimation, the mean absolute error was 2.35° and root mean squared error was 2.98°, with an accuracy of 94.7% for determining the presence or absence of the O–C2 angle (i.e., whether all 4 anatomical landmarks were simultaneously detected). Bland-Altman analysis revealed minimal bias (0.57°; 95% confidence interval, -0.06° to 1.12°) with limits of agreement from -5.19° to 6.33°. Inference time was approximately 0.14 s per image.
Conclusion Our deep learning model enables rapid and accurate O–C2 angle measurement on lateral cervical radiographs, demonstrating performance comparable to expert raters and potential clinical utility.
Objective To examine the factors influencing cervical sagittal alignment (CSA) after posterior correction and fusion surgery (PSF) for patients with Lenke type 2 adolescent idiopathic scoliosis (AIS).
Methods A total of 102 female patients with Lenke 2 AIS and a minimum 2-year follow-up were included. The upper instrumented vertebra was T2 in all patients. Sagittal and coronal parameters were measured before and 2 years after surgery. Patients were categorized into cervical malalignment (CM) and noncervical malalignment (NCM) groups following Passias’ criteria. Radiographic factors influencing CSA were analyzed.
Results Preoperatively, 57 patients (55.9%) were assigned to the CM group and 45 patients (44.1%) to the NCM groups. The cervical lordosis (CL) in CM group was more kyphotic (19.3° vs. 3.3°), smaller proximal thoracic kyphosis (PTK; 9.7° vs. 15.4°), and smaller T1 slope (7.1° vs. 14.0°) than those in the NCM group. Main thoracic kyphosis (MTK) did not show significantly difference between the 2 groups (11.3° vs. 14.4°). Two years after surgery, the CM group demonstrated significant improvements in CSA. PTK increased from 9.7° to 13.5°, T1 slope increased from 7.1° to 10.5°, and cervical kyphosis improved from -19.3° to -8.8°, while MTK remained unchanged (11.3° vs. 11.6°).
Conclusion PSF significantly improved CSA in patients with preoperative CM. Increased PTK, correlated with improved CL, suggests that PSF-induced PTK enhancement, rather than MTK, drives T1 slope and subsequent CSA improvement.
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Purpose To identify factors associated with adjacent-level ossification development (ALOD) after anterior cervical discectomy and fusion (ACDF) and associated clinical outcomes.
Methods We retrospectively reviewed records of 140 adults who underwent primary ACDF for degenerative disc disease. We compared patients with and without ALOD after ACDF. Radiographic measurements and factors associated with ALOD were assessed preoperatively and at minimum 24-month follow-up. Clinical outcomes were incidence of clinical adjacent-segment pathologies (CASP), revision surgery, and patient-reported outcomes.
Results Factors associated with both cranial and caudal ALOD were short plate-to-disc distance (PDD), adjacent-segment kyphosis, hyperlordotic ACDF causing junctional segment kyphosis, and preoperative ossification of the anterior longitudinal ligament (OALL). Mean final adjacent-segment range of motion (ROM) was less in those with cranial ALOD (6.9° ± 2.8°) than in those without cranial ALOD (12° ± 4.2°) (p < 0.01). Mean final adjacent-segment ROM was also less in those with caudal ALOD (5.5° ± 2.4º) than in those without caudal ALOD (8.2º ± 3.7º) (p < 0.01). The incidence of CASP-required surgery was higher in those with caudal ALOD (p = 0.02) but no different in those with cranial ALOD (p = 0.69) compared with those without ALOD.
Conclusion Factors associated with ALOD were a kyphotic segment adjacent to ACDF, hyperlordotic fusion, preoperative OALL, and short PDD. ALOD was associated with less segmental ROM and, for those with caudal but not cranial ALOD, higher incidence of revision surgery for CASP.
Objective To evaluate C2 muscle preservation effect and the radiological and clinical outcomes after C2 recapping laminoplasty.
Methods Fourteen consecutive patients who underwent C2 recapping laminoplasty around C1–2 level were enrolled. To evaluate muscle preservation effect, the authors conducted a morphological measurement of extensor muscles between the operated and nonoperated side. Two surgeons measured the cross-sectional area (CSA) of obliquus capitis inferior (OCI) and semispinalis cervicis (SSC) muscle before and after surgery to determine atrophy rates (ARs). Additionally, we examined range of motion (ROM), sagittal vertical axis (SVA), neck visual analogue scale (VAS), Neck Disability Index (NDI), and Japanese Orthopaedic Association (JOA) score to assess potential changes in alignment and consequent clinical outcomes following posterior cervical surgery.
Results We measured the CSA of OCI and SSC before surgery, and at 6 and 12 months postoperatively. Based on these measurements, the AR of the nonoperated SSC was 0.1% ± 8.5%, the AR of the operated OCI was 2.0% ± 7.2%, and the AR of the nonoperated OCI was -0.7% ± 5.1% at the 12 months after surgery. However, the AR of the operated side’s SSC was 11.2% ± 12.5%, which is a relatively higher value than other measurements. Despite the atrophic change of SSC on the operated side, there were no prominent changes observed in SVA, C0–2 ROM, and C2–7 ROM between preoperative and 12 months postoperative measurements, which were 11.8 ± 10.9 mm, 16.3° ± 5.9°, and 48.7° ± 7.7° preoperatively, and 14.1 ± 11.6 mm, 16.1° ± 7.2°, and 44.0° ± 10.3° at 12 months postoperative, respectively. Improvement was also noted in VAS, NDI, and JOA scores after surgery with JOA recovery rate of 77.3% ± 29.6%.
Conclusion C2 recapping laminoplasty could be a useful tool for addressing pathologies around the upper cervical spine, potentially mitigating muscle atrophy and reducing postoperative neck pain, while maintaining sagittal alignment and ROM.
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Objective Stereotactic radiosurgery (SRS) has been performed for spinal tumors. However, the quantitative effect of SRS on postoperative residual cervical dumbbell tumors remains unknown. This study aimed to quantitatively evaluate the efficacy of SRS for treating postoperative residual cervical dumbbell tumors.
Methods We retrospectively reviewed cases of postoperative residual cervical dumbbell tumors from 1995 to 2020 in 2 tertiary institutions. Residual tumors underwent SRS (SRS group) or were observed with clinical and magnetic resonance imaging (MRI) follow-up (observation group). Tumor regrowth rates were compared between the SRS and observation groups. Additionally, risk factors for tumor regrowth were analyzed.
Results A total of 28 cervical dumbbell tumors were incompletely resected. Eight patients were in the SRS group, and 20 in the observation group. The mean regrowth rate was not significantly lower (p = 0.784) in the SRS group (0.18 ± 0.29 mm/mo) than in the observation group (0.33 ± 0.40 mm/mo). In the multivariable Cox regression analysis, SRS was not a significant variable (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.18–1.79; p = 0.336).
Conclusion SRS did not significantly decrease the tumor regrowth rate in our study. We believe that achieving maximal resection during the initial operation is more important than postoperative adjuvant SRS.
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Methods Our study used the Healthcare Cost and Utilization Project’s National Inpatient Sample to assess patients undergoing CDA comparing patient characteristics and outcomes in nonobese patients to obese patients from 2004 to 2014.
Results Our study found a significant increase in the overall utilization of CDA as a treatment modality (p = 0.012) and a statistically significant increase in obese patients undergoing CDA (p < 0.0001) from 2004 to 2014. Obesity was identified as an independent risk factor associated with increased rates of inpatient neurologic complications (odds ratio [OR], 6.99; p = 0.03), pulmonary embolus (OR, 5.41; p = 0.05), and wound infection (OR, 6.97; p < 0.001) in patients undergoing CDA from 2004 to 2014.
Conclusion In patients undergoing CDA, from 2004 to 2014, obesity was identified as an independent risk factor with significantly increased rates of inpatient neurologic complications, pulmonary embolus and wound infection. Large prospective trials are needed to validate these findings.
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Objective Cerebrospinal fluid (CSF) leakage is a major concern related to anterior cervical decompression and fusion for ossification of the posterior longitudinal ligament (OPLL). We propose a management algorithm for CSF leakage following anterior cervical decompression and fusion for OPLL involving the use of pump-regulated volumetric continuous lumbar drainage.
Methods We retrospectively reviewed patients who underwent anterior cervical decompression and fusion for OPLL and were managed with the proposed algorithm between March 2018 and July 2022. The proposed management algorithm for CSF leakage by pump-regulated volumetric continuous lumbar drainage was as follows. On exposure of the arachnoid membrane with or without CSF leakage, a dural sealant patch was applied to manage the dural defect. In case of persistent CSF leakage despite application of the dural sealant patch, patients underwent pump-regulated volumetric continuous lumbar drainage.
Results Fifty-one patients were included in the study. CSF leakage occurred in 14 patients. Of these 14 patients, 9 patients underwent lumbar drain insertion according to the proposed management algorithm. Successful resolution of CSF leakage was observed in 8 of the 9 patients who underwent lumbar drainage. All patients were encouraged to ambulate without concern of CSF overdrainage due to gravity, because it could be avoided with pump-regulated volumetric continuous CSF drainage. Therefore, complications associated with absolute bed rest or CSF overdrainage were not observed.
Conclusion The proposed management algorithm with pump-regulated volumetric continuous lumbar drainage showed safety and efficacy for management of CSF leakage following anterior decompression and fusion for OPLL.
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Objective This retrospective cohort study has been aimed at evaluating the incidence of complications after vertebral body sliding osteotomy (VBSO) and analyzing some cases. Furthermore, the complications of VBSO were compared with those of anterior cervical corpectomy and fusion (ACCF).
Methods This study included 154 patients who underwent VBSO (n = 109) or ACCF (n = 45) for cervical myelopathy and were followed up for > 2 years. Surgical complications, clinical and radiological outcomes were analyzed.
Results The most common surgical complications after VBSO were dysphagia (n = 8, 7.3%) and significant subsidence (n = 6, 5.5%). There were 5 cases of C5 palsy (4.6%), followed by dysphonia (n = 4, 3.7%), implant failure (n = 3, 2.8%), pseudoarthrosis (n = 3, 2.8%), dural tears (n = 2, 1.8%), and reoperation (n = 2, 1.8%). C5 palsy and dysphagia did not require additional treatment and spontaneously resolved. The rates of reoperation (VBSO, 1.8%; ACCF, 11.1%; p = 0.02) and subsidence (VBSO, 5.5%; ACCF, 40%; p < 0.01) were significantly lower in VBSO than in ACCF. VBSO restored more C2–7 lordosis (VBSO, 13.9° ± 7.5°; ACCF, 10.1° ± 8.0°; p = 0.02) and segmental lordosis (VBSO, 15.7° ± 7.1°; ACCF, 6.6° ± 10.2°; p < 0.01) than ACCF. The clinical outcomes did not significantly differ between both groups.
Conclusion VBSO has advantages over ACCF in terms of low rate of surgical complications related to reoperation and significant subsidence. However, dural tears may still occur despite the lessened need for ossified posterior longitudinal ligament lesion manipulation in VBSO; hence, caution is warranted.
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Objective Endoscopic posterior cervical foraminotomy (PCF) using uniportal or biportal endoscopic approach has been performed for cervical foraminal stenosis or foraminal disc herniation. Two-level PCF is possible using a single biportal endoscopic approach. The purpose of this study was to present a technique of biportal endoscopic PCF for contiguous 2-level foraminal lesions using a single approach and its clinical results.
Methods Patients who received 2-level PCF using a single biportal endoscopic approach were enrolled in this study. We analyzed their clinical data including age, sex, complications, and Neck Disability Index (NDI), and visual analogue scale (VAS) of neck and arm. Postoperative magnetic resonance image was taken on the first postoperative day to determine whether there was sufficient decompression.
Results We successfully performed biportal endoscopic PCF for adjacent 2-level foraminal lesions using a single approach (sliding technique) in all 12 patients. There were cervical foraminal disc herniation with foraminal stenosis (5 cases) and 2-level foraminal stenosis (7 cases). Preoperative mean NDI and VAS of arm and neck significantly decreased at 12 months after surgery. Postoperative clinical outcomes were excellent in 5 patients, good in 6 patients, and fair in 1 patient. There was no major complication.
Conclusion Two-level PCF could be performed using a single approach biportal endoscopic surgery with only 2 skin incisions. Clinical outcomes are favorable. This sliding PCF technique using biportal endoscopic approach might be an alternative surgical treatment for contiguous 2-level cervical foraminal pathologic lesions.
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Objective Robot-assisted (RA) techniques have been widely investigated in thoracolumbar spine surgery. However, the application of RA methods on cervical spine surgery is rare due to the complex morphology of cervical vertebrae and catastrophic complications. Thus, the feasibility and safety of RA cervical screw placement remain controversial. This study aims to evaluate the feasibility and safety of RA screw placement on cervical spine surgery.
Methods A comprehensive search on PubMed, Cochrane Library, Embase Database, Web of Science, Chinese National Knowledge Databases, and Wanfang Database was performed to select potential eligible studies. Randomized controlled trials (RCTs), comparative cohort studies, and case series reporting the accuracy of cervical screw placement were included. The Cochrane risk of bias criteria and Newcastle-Ottawa Scale criteria were utilized to rate the risk of bias of the included literatures. The primary outcome was the rate of cervical screw placement accuracy with robotic guidance; subgroup analyses based on the screw type and insertion segments were also performed.
Results One RCT, 3 comparative cohort studies, and 3 case series consisting of 160 patients and 719 cervical screws were included in this meta-analysis. The combined outcomes indicated that the rates of optimal and clinically acceptable cervical screw placement accuracy under robotic guidance were 88.0% (95% confidence interval [CI], 84.1%–91.4%; p = 0.073; I2 = 47.941%) and 98.4% (95% CI, 96.8%–99.5%; p = 0.167; I2 = 35.954%). The subgroup analyses showed that the rate of optimal pedicle screw placement accuracy was 88.2% (95% CI, 83.1%–92.6%; p = 0.057; I2 = 53.305%); the rates of optimal screw placement accuracy on C1, C2, and subaxial segments were 96.2% (95% CI, 80.5%–100.0%; p = 0.167; I2 = 44.134X%), 89.7% (95% CI, 80.6%–96.6%; p = 0.370; I2 = 0.000X%), and 82.6% (95% CI, 70.9%–91.9%; p = 0.057; I2 = 65.127X%;), respectively.
Conclusion RA techniques were associated with high rates of optimal and clinically acceptable screw positions. RA cervical screw placement is accurate, safe, and feasible in cervical spine surgery with promising clinical potential.
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The complex nature of the cervical spine makes surgical intervention challenging when treating cervical deformity in patients with cerebral palsy (CDCP). However, few studies have investigated the unique characteristics of cerebral palsy that create the need for surgery, the most effective surgical strategies, and the possible perioperative complications. The intended benefit and the potential risk of postoperative complications must be considered when deciding to operate for CDCP. Because the approach and correction strategy depend on the type of cervical deformity, as well as the patient’s comorbidities and functional status, a customized strategy is needed. Perioperatively, botulinum toxin injections and muscle division techniques can help control excessive involuntary movements and improve the spinal fusion success rate. Surgical intervention for CDCP requires a multidisciplinary approach, and the information presented in this article is intended to help in the perioperative management and surgical treatment of CDCP.
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Objective Subsidence following anterior cervical discectomy and fusion (ACDF) may lead to disruptions of cervical alignment and lordosis. The purpose of this study was to evaluate the effect of subsidence on segmental, regional, and global lordosis.
Methods This was a retrospective cohort study performed between 2016–2021 at a single institution. All measurements were performed using lateral cervical radiographs at the immediate postoperative period and at final follow-up greater than 6 months after surgery. Associations between subsidence and segmental lordosis, total fused lordosis, C2–7 lordosis, and cervical sagittal vertical alignment change were determined using Pearson correlation and multivariate logistic regression analyses.
Results One hundred thirty-one patients and 244 levels were included in the study. There were 41 one-level fusions, 67 two-level fusions, and 23 three-level fusions. The median follow-up time was 366 days (interquartile range, 239–566 days). Segmental subsidence was significantly negatively associated with segmental lordosis change in the Pearson (r = -0.154, p = 0.016) and multivariate analyses (beta = -3.78; 95% confidence interval, -7.15 to -0.42; p = 0.028) but no associations between segmental or total fused subsidence and any other measures of cervical alignment were observed.
Conclusion We found that subsidence is associated with segmental lordosis loss 6 months following ACDF. Surgeons should minimize subsidence to prevent long-term clinical symptoms associated with poor cervical alignment.
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Objective We compared the midterm clinical and radiological outcomes between 2 types of full endoscopic posterior cervical foraminotomy, including conventional posterior endoscopic cervical foraminotomy (PECF) and modified inclined technique for PECF.
Methods One of the 2 types of PECF surgery was performed for defined cervical foraminal stenosis. The foraminal expansion ratio and facet resection rate and foraminal stenosis grade were measured using magnetic resonance imaging. Visual analogue scale (VAS) scores for neck and arm pain, neck disability index, MacNab criteria, operation time, hospital stay, and complications, including postoperative dysesthesia, were assessed. Clinical and radiological parameters were compared between the 2 surgical groups.
Results There were 49 and 46 patients in the PECF and modified-PECF groups, respectively. The modified-PECF group showed significantly higher expansion of distal foraminal diameter and foraminal height, and a lower facet resection rate compared to PECF group (in all, p < 0.001). The modified-PECF group displayed significantly lower VAS score for neck pain at 1 day and 1 week after surgery and lower arm pain VAS score after 6-month follow-up (p = 0.002, p = 0.001, p = 0.002, respectively).
Conclusion Compared with the PECF, the modified inclined technique has radiologic benefits, including enhanced facet joint preservation, restoration of the natural course of nerve roots, and prevention of restenosis by expanding the superior articular process base, especially in grade 2 foraminal stenosis. Furthermore, the modified inclined technique significantly improved the postoperative VAS score for neck pain within the 1-week follow-up and that of arm pain after 6-month follow-up.
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Objective The aim of this study was to compare the clinical and radiologic outcomes of 3 types of minimally invasive posterior cervical foraminotomy (PCF): uniportal endoscopic surgery, biportal endoscopic surgery, and microsurgery.
Methods Between January 2019 to January 2020, PCF was performed using 3 different approaches to treat foraminal stenosis. The foraminal expansion rate, facet resection rate, and surgical foraminal approach angle were measured using magnetic resonance imaging. Visual analogue scale (VAS) scores for neck and arm pain, neck disability index (NDI), MacNab criteria, operation time, hospital stay, and complications were assessed. Clinical and radiologic parameters were compared among the 3 surgical groups.
Results There were 38, 30, and 50 patients in the uniportal endoscopy, biportal endoscopy, and microscopy groups, respectively. Microscopy group displayed significantly higher foraminal expansion compared to uniportal endoscopy group (p = 0.001). Facet resection rates and inclination angle for facet joint undercutting were significantly different among the 3 groups. Uniportal endoscopy group had the highest inclination angle and the least facet resection. On the 6 months and final follow-up, VAS scores and NDI were significantly lower in the uniportal endoscopy group than in the microscopy group (p = 0.000).
Conclusion All 3 types of PCF displayed favorable clinical outcomes and sufficient expansion of the midforaminal area. Two endoscopy groups showed a significantly higher inclination angle for undercutting the facet joint and a lower facet resection rate than the microscopy group. Reduced facet joint resection using an inclinatory approach did not interfere with sufficient foraminal expansion and enhanced the clinical result after 6 months of follow-up.
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