Surgical treatment of dropped head syndrome secondary to fascioscapulohumeral muscle dystrophy: a case report

Fascioscapulohumeral muscular dystrophy is an uncommon hereditary myopathy which affects mainly the muscle of the face and upper limb girdle. We present a rare case with dropped head syndrome as the prominent manifestation of that disease and successfully treated by surgical management. It was a 25-year-old male patient with the chief complaint of neck pain and inability to maintain his horizontal gaze for long periods and as a result he had to quit his job as a shipper. His mother also had signs and symptoms of fascioscapulohumeral muscle dystrophy. Conservative treatment consisting of physical therapy and hard collar was the first attempt in order to reduce the neck pain and had limited result. We then performed a posterior cervical surgery including C2 to T2 instrumentation and kyphotic correction for the patient. The ten-month postop clinical and radiological results were satisfactory and the patient could return to his previous job. Dropped head syndrome with failed conservative treatment can be surgically treated after considering all clinical and radiographic factors.

Machine learning with interpretability predict surgical site infection after posterior cervical surgery

Background: Ideal tools should not only investigate risk factors, but also provide explicit auxiliary answer for whether a patient will develop surgical site infection (SSI) or not. Machine learning (ML) models have ability to carry out complicated predictive medical tasks. We intend to develop ML models to predict SSI after posterior cervical surgery and interpret the outcome. Methods: We retrospectively analyzed 235 patients who had undergone posterior cervical surgery between June 2013 to April 2019 at Zhongda Hospital Affiliated to Southeast University. We established Artificial neural networks (ANN), XGBClassifier (xgboost), KNeighborsClassifier (KNN), Decision tree classifier (decision tree), Random forest classifier (random forest) and support vector classifier (SVC). Receiver operating characteristic (ROC) curve, area under the curve (AUC) score, accuracy score, recall score, F1 score and precision score were calculated to measure models’ performance. Shapley values were calculated using SHapley Additive exPlanations (SHAP) to determine relative feature importance of xgboost model. Results: The incidence of SSI was 7.23%. With AUC of 0.9972, 0.9923, 0.9865, 0.9615, 0.9540, 0.8934, the xgboost, random forest, ANN, KNN, decision tree, SCV accurately predicted SSI. Xgboost, ANN, decision tree and random forest achieved excellent performance in testing set. Top 10 variables with high predictive contribution of xgboost including, drainage volume, body mass index (BMI), drainage duration, operation blooding, cholesterin, sex, prognostic nutritional index (PNI), albumin, hypertension, operation time. Conclusion: We had successful established ML models in individualized predicting SSI after posterior cervical surgery. Xgboost, ANN, decision tree and random forest achieved excellent performance which could provide auxiliary information for clinical decision makers. The interpretable model focuses on contribution of important features to the predictive result. It can improve the acceptance of clinicians on ML and promote ML’s application in the actual clinical work.

Misdiagnosis of “White Cord Syndrome” following posterior cervical surgery for ossification of the posterior longitudinal ligament: A case report

Background: Following decompressive cervical surgery for significant spinal cord compression/myelopathy, patients may rarely develop the “White Cord Syndrome (WCS).” This acute postoperative reperfusion injury is characterized on T2W MRI images by an increased intramedullary cord signal. However, it is a diagnosis of exclusion, and WCS can only be invoked once all other etiologies for cord injury have been ruled out. Case Description: A 49-year-old male, 3 days following a C3-C7 cervical laminectomy and C2-T1 fusion for extensive cord compression due to ossification of the posterior longitudinal ligament (OPLL), developed acute quadriparesis. This new deficit should have been attributed to an intraoperative iatrogenic cord injury, not the WCS. Conclusion: Very rarely patients sustain postoperative significant/severe new neurological deficits attributable to the WCS. Notably, the WCS is a diagnosis of exclusion, and all other etiologies (i.e. intraoperative iatrogenic surgeon-based mechanical cord injury, graft/instrumentation extrusion, failure to adequately remove/resect OPLL thus stretching cord over residual disease, other reasons for continued cord compression, including the need for secondary surgery, etc.) of cord injury must first be ruled out.

Radiological influencing factors of the effectiveness of posterior cervical surgery for multilevel ossification of the posterior longitudinal ligament

Background In patients with multilevel cervical ossification of posterior longitudinal ligament (OPLL), whether radiological factors affect the efficacy of posterior cervical surgery and which posterior surgery is more suitable and better in patients with different imaging manifestations remain to be elucidated. Methods From January 2012 to January 2018, 141 patients with multi-segmental OPLL underwent posterior cervical surgery, including 73 cases of laminoplasty (LP group) and 68 cases of laminectomy with fusion (LF group). Clinical and radiological results were compared between the groups. Patients were followed up for at least 2 years. Results At the last follow-up, significant differences in neck disability index (NDI), cervical range of motion, and C2–C7 Cobb angle were found between the two groups (P < 0.05). In the cervical kyphosis, K-line-negative, and OPLL occupying ratio(OR) > 60% groups, the

Comparison of Accuracy and Clinical Outcomes of Robot-Assisted Versus Fluoroscopy-Guided Pedicle Screw Placement in Posterior Cervical Surgery

Study Design: This was a prospective controlled study. Objective: To compare the accuracy and clinical outcomes of robot-assisted (RA) and fluoroscopy-guided (FG) pedicle screw placement in posterior cervical surgery. Methods: This study included 58 patients. The primary outcome measures were the 1-time success rate and the accuracy of pedicle screw placement according to the Gertzbein-Robbins scales. The secondary outcome measures, including the operative time, intraoperative blood loss, hospital stay, cumulative radiation time, radiation dose, intraoperative advent events, and postoperative complications, were recorded and analyzed. The Japanese Orthopedics Association (JOA) scores and Neck Disability Index (NDI) were used to assess the neurological function of patients before and at 3 and 6 months after surgery. Results: The rate of grade A was significantly higher in the RA group than in the FG group (90.6% and 71.1%; P < .001). The clinically acceptable accuracy was 97.2% in the RA group and 90.7% in the FG group ( P = .009). Moreover, the 1-time success rate was significantly higher in the RA group than in the FG group. The RA group had less radiation time ( P < .001) and less radiation dose ( P = .002) but longer operative time ( P = .001). There were no significant differences in terms of intraoperative blood loss, hospital stay, intraoperative adverse events, postoperative complications, JOA scores, and NDI scores at each follow-up time point between the 2 groups. Conclusions: The RA technique achieved higher accuracy and 1-time success rate of pedicle screw placement in posterior cervical surgery while achieving comparable clinical outcomes.

Surgical Site Infection Prevention Following Spine Surgery

Study Design: Literature review. Objectives: Surgical site infection (SSI) following spine surgery leads to significant patient morbidity, mortality, and increased health care costs. The purpose of this article is to identify risk factors and strategies to prevent SSIs following spine surgery, with particular focus on avoiding infections in posterior cervical surgery. Methods: We performed a literature review and synthesis to identify methods that can be used to prevent the development of SSI following spine surgery. Specific pearls for preventing infection in posterior cervical spine surgery are also presented. Results: SSI prevention can be divided into patient and surgeon factors. Preoperative patient factors include smoking cessation, tight glycemic control, weight loss, and nutrition optimization. Surgeon factors include screening and treatment for pathologic microorganisms, skin preparation using chlorhexidine and alcohol, antimicrobial prophylaxis, hand hygiene, meticulous surgical technique, frequent irrigation, intrawound vancomycin powder, meticulous multilayered closure, and use of closed suction drains. Conclusion: Prevention of SSI following spine surgery is multifactorial and begins with careful patient selection, preoperative optimization, and meticulous attention to numerous surgical factors. With careful attention to various patient and surgeon factors, it is possible to significantly reduce SSI rates following spine surgery.