Comparison of Interventions for Cervical Ossification of Posterior Longitudinal Ligament: A Systematic Review and Network Meta-Analysis

Ossification of posterior longitudinal ligament of the cervical spine: A review article

This article reviews the literature on the status of cervical OPLL in recent years, and reviews the etiology, clinical manifestations, imaging features, treatment and prognosis. Evidence was collected through PubMed and Google Scholar databases. After screening, weight removal and irrelevant articles, 57 articles were finally included in the review. Imaging is the only way to confirm the diagnosis, and CT and MRI are used to assess the patient's ossified material and spinal cord compression. Because there are hundreds of surgical approaches to cervical OPLL, each with advantages and disadvantages, clinicians must develop a personalized surgical plan based on the patient's preoperative relevant factors to maximize prognosis. Clinicians should also actively follow up on discharged patients, carefully analyze cases with a poor prognosis, and summarize their experiences.

Metabolomic differences between exanthematous drug eruption and infectious mononucleosis

BACKGROUND

Exanthematous drug eruption and infectious mononucleosis (IM) are both exanthematous diseases. Current research on exanthematous drug eruption and IM mainly targets identifying these disorders, the resulting differences at the metabolism level have not yet been systematically analyzed.

MATERIALS AND METHODS

A total of 30 cases of exanthematous drug eruption and IM, 10 patients without exanthema and 10 healthy volunteers were enrolled, 3 mL of fasting venous blood was collected, the serum metabolite content was detected by gas chromatography-mass spectrometry metabolomics.

RESULTS

A total of 165 metabolites were identified, exhibiting significant differences in plasma metabolic trends between exanthematous drug eruption and IM, and pinpointed 28 potential biomarkers. Notable changes were seen in the metabolic activities of the pentose phosphate pathway (PPP), tricarboxylic acid cycle (TCA-cycle), and galactose metabolism, characterized by increased levels of gluconate, gluconolactone, glucose, galactaric acid, and mannose, along with decreased amounts of pyruvic acid, succinic acid, malic acid, and glycerol, indicating an impairment in the exanthematous drug eruption group's capacity to endure oxidative stress and regulate energy metabolism. In contrast to its medication without rash counterpart, the exanthematous drug eruption group's plasma displayed distinct metabolic routes, predominantly in the processing of arginine and proline, along with the TCA. This resulted in a marked reduction in urea levels and a rise in pyruvate, citrate, and ornithine, indicating hypoxic stress as the primary cause of these rashes. In contrast to the healthy control group, the IM group showed 26 potential biomarkers, marked by increased levels of ketoglutaric acid, malic acid, pyruvic acid, and oxoglutaric acid, and reduced amounts of glutamine, galacturonic acid, arachidonic acid, trimethylphosphonic acid ester, gluconolactone, and indole acetic acid. Mainly, the metabolic pathways included the TCA, breaking down alanine, aspartate and glutamate metabolism, and the processing of D-glutamine and D-glutamate metabolism, underscoring the body's crucial role in generating energy and inflammatory agents through the citric acid cycle.

CONCLUSIONS

The comparison of serum metabolomic features of exanthematous drug eruptions and IM outlines a unique pattern closely related to the differences in the pathogenesis of these two exanthematous diseases.

Comparison of Anterior Controllable Antedisplacement and Fusion Versus Laminoplasty in the Treatment of Multisegment Ossification of Cervical Posterior Longitudinal Ligament: A Meta-Analysis of Clinical

OBJECTIVE

This study aims to provide a comprehensive summary of the existing literature and conduct a systematic evaluation of the clinical outcomes associated with anterior controllable antedisplacement and fusion (ACAF) and posterior laminoplasty (LP) for the treatment of multisegment ossification of the cervical posterior longitudinal ligament (OPLL).

METHODS

We conducted an electronic search of databases, including PubMed, Embase, Cochrane Library, and CNKI, from the inception of the initial database to March 2023. We analyzed various parameters, including demographic data, operation time, intraoperative blood loss, cervical curvature, Japanese Orthopaedic Association (JOA) scores, Visual Analog Scale (VAS) scores, and postoperative complications. Two independent reviewers screened the literature, extracted data, and assessed the risk of bias in the included studies. Meta-analysis was performed using RevMan 5.4 software.

RESULTS

Our evaluation encompassed 7 studies involving a total of 467 patients. The patient cohort was divided into 2 groups: Group A (ACAF) comprised 226 patients, while Group B (LP) comprised 241 patients. Overall, our statistical analysis revealed significant differences between the 2 groups (P < 0.05) in terms of intraoperative blood loss, operative time, JOA score, JOA score improvement rate, postoperative VAS score, postoperative cervical curvature, and the incidence of certain postoperative complications (C5 nerve root paralysis, dysphagia, and axial symptoms). However, there was no statistically significant difference in the incidence of postoperative cerebrospinal fluid leakage and postoperative total complications between the 2 groups (P > 0.05).

CONCLUSIONS

The findings of this study suggest that, in the treatment of multilevel cervical OPLL, ACAF yields superior outcomes compared to LP. Specifically, ACAF improves postoperative neurologic function, reduces postoperative pain, lowers intraoperative blood loss, improves postoperative cervical curvature, and decreases the incidence of C5 nerve root paralysis and postoperative axial symptoms. Nonetheless, ACAF is associated with longer operative times and a higher incidence of postoperative dysphagia, though the overall incidence of postoperative complications is similar. It is important to note that these conclusions should be interpreted cautiously due to the limited sample size and the variable quality of the included studies. Further research involving larger, high-quality studies is warranted to validate these findings.

Significance of O-Arm Assisted Anterior Controllable Antedisplacement and Fusion Surgery in Treatment of Cervical Ossification of Posterior Longitudinal Ligament

BACKGROUND

Anterior controllable antedisplacement and fusion (ACAF) surgery for cervical OPLL is commonly used in clinical practice and has shown promising results. Nonetheless, precise slotting and lifting are the most critical procedures in ACAF surgery to avoid several unique and dangerous problems, such as residual ossification and incomplete lifting. C-arm intraoperative imaging can help with traditional cervical surgery but not with the precise slotting and lifting operation in ACAF surgery.

METHODS

Fifty-five patients admitted to our department with cervical OPLL were retrospectively enrolled. Given the selection of intraoperative imaging technique, patients were divided into the C-arm group and O-arm group. The operation time, intraoperative blood loss, hospital stay, Japanese Orthopaedic Association score, Oswestry Disability Index score, visual analog scale score, slotting grade, lifting grade, and complications were recorded and analyzed.

RESULTS

At the final follow-up, all patients acquired satisfactory improvement of neurologic function. Patients in the O-arm group, on the other hand, had a better neurologic state 6 months after surgery and at the final follow-up than those in the C-arm group. Furthermore, slotting and lifting grade were considerably higher in the O-arm group than in the C-arm group. No severe complications were encountered in both groups.

CONCLUSIONS

O-arm assisted ACAF can achieve accurate slotting and lifting, which might effectively reduce the occurrence of complications and is worthy of clinical application.

The effect of K-line classification in different cervical dynamic position on surgical outcomes in patients with ossification of the posterior longitudinal ligament after anterior controllable antedisplacement and fusion

Purpose

To investigate whether the K-line classification in different cervical dynamic position of patients with Ossification of the Posterior Longitudinal Ligament (OPLL) affects clinical outcome after Anterior Controllable Antedisplacement and Fusion (ACAF) surgery.

Methods

A total of 93 patients who suffered from cervical spondylosis caused by OPLL underwent ACAF surgery between June 2015 and December 2017 in a single institution. Neutral, neck-flexed and neck-extended cervical radiographs were obtained from every patient. Subsequently they were classified into K-line (+) and K-line (−) with reference to the K-line classification criteria. Clinical outcomes were assessed by the JOA score, improvement rate (IR) and visual analogue scale (VAS). Radiological assessment included Cobb angle and occupation ratio (OR) of OPLL. Correlations between the long-term surgical outcomes and classification of K-line in different dynamic position were analyzed by one-way analysis of variance.

Results

Significant improvements were shown in all postoperative clinical and radiographic assessments (P < 0.05). There were no differences in IR, Cobb angle and VAS among flexion K-line (−), flexion K-line (+), extension K-line (−) and extension K-line (+) at the 2-year follow-up (P > 0.05). However, the OR of extension K-line (−) (16.13% ± 11.58%) was higher than that of extension K-line (+) (9.00% ± 10.27%) and flexion K-line (+) subgroup (9.47% ± 9.97%) (P < 0.05).

Conclusion

The ACAF procedure has shown satisfactory surgical outcomes in various K-line classifications in different dynamic position.

Anterior controllable antedisplacement and fusion: quantitative analysis of a single surgeon's learning experience

BACKGROUND CONTEXT

Anterior controllable antedisplacement and fusion (ACAF) is a novel surgical technique for the treatment of ossification of the posterior longitudinal ligament (OPLL) but the surgical learning curve for this technique has not been previously characterized.

PURPOSE

The aim of this study was to quantify a surgeon's learning curve for ACAF and the effect of surgeon experience on postoperative outcomes.

STUDY DESIGN

Prospective study of a single institution and single surgeon experience with ACAF surgery.

PATIENT SAMPLE

A total of 70 consecutive patients with OPLL undergoing ACAF surgery by a single, non-ACAF trained surgeon between 2017 and 2020 were analyzed.

OUTCOME MEASURES

Intraoperative and postoperative outcomes (blood loss, operative time, errors of surgical procedure, length of hospital stay, Japanese Orthopedic Association (JOA) scoring system, and surgical complications) were assessed.

METHODS

We prospectively reviewed the first 70 ACAF procedures between 2017 and 2020 performed by a single, non-ACAF trained surgeon. The function relationship between the operative time and case number was fitted using a locally weighted scatterplot smoothing (LOESS) plot. Spearman's correlation analysis was performed to determine factors affecting the operative time. The operative time-related learning curve for ACAF was established and difficulty of each procedure was assessed using a cumulative sum (CUSUM) model. The association between the specific errors of surgical procedures and surgeon experience was further analyzed. A modified CUSUM model was also used to establish the surgical procedure-related learning curve, and thus whether these two learning curves matched with each other was observed. Postoperative outcomes in relation to surgeon experience was compared using a Wilcoxon rank sum test and Chi-squared test.

RESULTS

Operative time presented a specific pattern of fewer patient-dependent changes as the case number increased. Spearman's correlation analysis showed the operative time was more affected by the case number (r=-0.73) than the complexity of condition and number of levels hoisted. The operative time-related CUSUM model identified the early (first 29 cases) and late phase (late 41 cases) of the learning process, which was also confirmed by a modified CUSUM model based on surgical procedure. The critical point of the CUSUM model for bilateral osteotomies was at case number 29, and time reduction after the early phase was approximately 34 minutes. Length of hospital stay and blood loss were less during the late phase than during the early phase (p<.05). Although no significant difference was observed in postoperative JOA scores between two phases, patients in the late phase obtained higher recovery rates of neurologic function than those in the early phase (p<.01). There was significant difference in the number of specific errors between the two phases (p=.02). There were no significant differences in overall complication rates between two phases, but a higher incidence of certain complications caused by specific errors was observed in the early phase (p=.02), including CSF leakage, C5 palsy and incomplete decompression.

CONCLUSIONS

We described, for the first time, a detailed learning curve for ACAF surgery. About 29 cases were needed to achieve mastery of ACAF. Once mastered, the surgeon could deal with various OPLL presentations in a universal way regardless of condition complexity and number of surgical levels. Bilateral osteotomies were the most difficult part of ACAF and produced the greatest reduction in time after mastery. We found a close association between specific errors of surgical procedure for ACAF and surgeon experience. Furthermore, certain complications caused by these errors should be on the alert during the early phase of learning ACAF, including CSF leakage, C5 palsy and incomplete decompression.