Introduction: With the older population, the number of patients on antithrombotic therapy for cardiovascular and cerebrovascular conditions continues to increase. This study aimed to investigate the effects of antithrombotic drug usage in patients with cervical spine and spinal cord injuries.

Methods: A total of 425 cases of cervical spine and spinal cord injuries treated surgically at our institution were analyzed. Patients were divided into two groups: 46 who were taking antithrombotic drugs at the time of injury (antithrombotic group) and 379 who were not (non-antithrombotic group). Variables analyzed included age at injury, mechanism of injury, type of injury, surgical procedures, perioperative complications, and AIS (ASIA Impairment Scale) classifications at initial presentation and final follow-up.

Results: The mean age at injury was significantly higher in the antithrombotic group (75.4 years) than in the non-antithrombotic group (62.0 years; p < 0.01). The mean intraoperative blood loss was significantly greater in the antithrombotic group (178 ml) than in the non-antithrombotic group (118 ml; p < 0.05). The incidence of perioperative systemic complications was significantly higher in the antithrombotic group (52.2%) than in the non-antithrombotic group (33.0%). No significant differences were observed between the groups regarding injury mechanism, type of injury, surgical time, improvement in paralysis, or incidence of thromboembolism.

Conclusions: In older patients with cervical spine and spinal cord injuries who are on antithrombotic therapy for ischemic vascular diseases, intraoperative blood loss is higher, and systemic complications occur more frequently after surgery. These risks should be carefully considered in managing such patients.

Introduction: During trans-sacral canal plasty (TSCP), instances of catheter damage and challenges in dissecting adhesions were observed. The purpose of this study was to investigate the radiological characteristics of patients in which difficulties were experienced during TSCP, aiming to improve preoperative assessment and procedural safety.

Methods: A total of 37 patients who underwent TSCP during the early stage of its implementation were included in this study. The study comprised two main analyses. The first examined the difficulty of catheter insertion in the sacral vertebral region, grading cases from 1 (easy) to 4 (unable to advance to the L5/S1 level). Radiological parameters included the anteroposterior diameter of the narrowest part of the spinal canal on computed tomography (CT) sagittal images [A], the sacral kyphosis angle [B], and the distance between the sacral hiatus and the posterior superior margin of S1 [C]. The second analysis focused on the difficulty of adhesion dissection in the lumbar region, graded from 1 to 3, with Grade 3 indicating cases where dissection was not achieved. Parameters for the lumbar spine included the spinal canal cross-sectional area [D], percentage (%) slip rate [E], and intervertebral wedge angle [F]. Data were analyzed to compare these radiological parameters across different difficulty levels for both sacral insertion and lumbar adhesion dissection.

Results: 1. For sacral catheter insertion, parameter [A] was significantly smaller in Grades 3 and 4 compared to Grade 1, and also narrower in Grades 3 and 4 compared to Grade 2. This suggests that a narrower anteroposterior sacral canal diameter increases insertion difficulty.

2. For lumbar adhesion dissection, parameter [D] was significantly smaller in Grade 2 compared to Grade 1, indicating that reduced lumbar spinal canal area is associated with higher difficulty in adhesion dissection.

Conclusions: In cases with difficulty implementing TSCP, narrower diameters of the sacral canal and smaller cross-sectional areas of the lumbar spinal canal were observed, suggesting that these features increase procedural difficulty. These findings emphasize the importance of detailed preoperative imaging evaluations to predict and address potential challenges, thereby reducing complications. Implementing thorough imaging assessments can contribute to safer and more effective TSCP procedures, improving outcomes.

Introduction: There are scattered reports on the efficacy of intradiscal condoliase injection therapy for lumbar disc herniation. However, there are few reports focused on discectomy after condoliase. In this study, we examined the characteristics of patients who underwent discectomy after condoliase injection.

Methods: The study included 200 consecutive patients (127 men and 73 women) who received intravertebral condoliase injection therapy from December 2018 to July 2023. The mean age was 46.2 years (15-89). The time from onset to injection was 25.7±32.2 weeks, and tension sign before injection was positive in 146 patients (73%). We investigated the visual analog scale scores for low back and leg pain, and the Oswestry Disability Index as clinical assessments. The conversion to discectomy and the timing of the conversion were investigated. Imaging evaluation included herniation size transition and progressive disc degeneration using before and one month after injection magnetic resonance imaging (MRI), and the presence of type 2 (T2) high-signal areas within the herniation on pre-injection MRI.

Results: The mean visual analog scale score for low back pain improved significantly from 5.4 cm pre-injection to 3.4 cm post-injection, and that of leg pain improved significantly from 7.0 to 3.7 cm. The Oswestry Disability Index also improved significantly from 42.4% to 26.8%. Herniation size decreased from 56.8 mm² pre-injection to 43.5 mm² post-injection. Disc degeneration was mildly progressed in 109 patients (56.2%). T2 high-signal areas were present in 111 patients (55.5%). Discectomy after condoliase was performed in 16 patients (8%) at 11.5±10.7 weeks after injection. The conversion group was older than other groups (57.3±16.5 vs. 45.3±17.7 years, p = 0.014), had a lower rate of positive tension signs (50% vs. 75%, p = 0.031), and was more likely to have no T2 high-signal area in the herniation on pre-injection MRI (25% vs. 58.2%, p = 0.011).

Conclusions: Discectomy after condoliase was performed in 8% of patients, with a mean time of 11.5 weeks after injection. The characteristics of conversion to discectomy were older age, negative tension signs, and lack of T2 high signal in the herniation on MRI.

Introduction: Adult patients with spinal deformity were admitted for spinal and general examination, physical evaluation, and pre- and postoperative lifestyle rehabilitation guidance. We investigated the reasons surgery was canceled after admission for examination and examined the influence of admission for examination on the decision to have surgery.

Methods: The subjects were patients who were hospitalized between January 2018 and January 2023. The reasons the patients did not undergo surgery were investigated from medical records. Patient background, patient-reported outcome, and spinopelvic parameters were compared.

Results: A total of 207 patients (mean age 70 years) were hospitalized for examination, and 36 patients (17.4%) (Non Op group) canceled surgery after hospitalization for examination. The main reasons for discontinuation were mild symptoms (7), surgery in other parts (5), diagnosis of neurological disease (3), and postoperative lifestyle (17). The mean values of height, weight, sacral slope, and pelvic incidence were significantly lower in the Non Op group than in the Op group (171 patients).

Conclusions: Patients' and diagnostic factors led to the cancellation of surgery after admission for examination, and thorough medical examination and explanation are important for the decision to operate.

Introduction: Vertebral body stenting (VBS) is a new option of a minimally invasive treatment for osteoporotic vertebral fractures (OVF). This study aimed to compare the outcomes of VBS with those of balloon kyphoplasty (BKP). Propensity score matching (PSM) was used to adjust for background factors.

Methods: In this retrospective cohort study, patients who underwent VBS or BKP for OVF from 2013 to June 2023 were included. The minimum follow-up period was 3 months; 92 patients (22 men, 70 women, mean age 79.0 years) and 103 vertebrae were analyzed. Patients were propensity score matched in a logistic regression model adjusted for age, sex, time from injury to surgery (weeks), fractured vertebra (T1-9, T10-L2, L3-5), bone density T score, preoperative neurological symptoms, Arbeitsgemeinschaft für Osteosynthesefragen Spine-Deutsche Gesellschaft für Orthopädie und Unfallchirurgie Osteoporotic Fracture classification system, preoperative vertebral body height (%), preoperative vertebral body wedge angle, and local kyphosis angle. Next, we analyzed reoperation, occurrence of adjacent vertebral fracture, postoperative vertebral body height (%), vertebral body wedging angle, and local kyphosis angle.

Results: VBS was performed on 37 vertebrae and BKP on 66 vertebrae. The time from injury to surgery was significantly shorter in VBS (p = 0.003). One-to-one matching generated 24 pairs of VBS and BKP cases. Reoperations were performed in 1 case in each group of VBS and BKP (4.2%). Adjacent vertebral fractures occurred in 6 cases (25%) in the VBS group and in 4 cases (16.6%) in the BKP group (p = 0.48). The vertebral body height (pre-operative/post-operative/3 m) was 64.4%/79.1%/76.6% in the VBS group and 69.6%/77.5%/74.3% in the BKP group; the vertebral body wedging angle was 11.1°/4.8°/7.0° in the VBS group and 12.6°/10.3°/11.2° in the BKP group, and the local kyphosis angle was 6.6°/3.7°/6.7° in the VBS group and 9.9°/11.5°/14.8° in the BKP group. The local kyphosis angle was 6.6°/3.6°/6.7° in the VBS group and 9.9°/11.5°/14.8° in the BKP group. A statistically significant difference was found at 1w/3 m vertebral wedge angle (p = 0.001/p = 0.02).

Conclusions: This study was the first to compare VBS and BKP using PSM. VBS was superior to BKP in vertebral body realignment and maintenance. VBS was not able to maintain the local kyphosis angle and prevent adjacent vertebral fractures.

Introduction: We investigated the characteristics of patients who can accept a postoperative pelvic incidence (PI) -lumbar lordosis (LL) > 10° in adult spinal deformity surgery.

Methods: Among the 156 patients with adult spinal deformity (ASD) who underwent circumferential minimally invasive (CMIS) using lateral lumbar interbody fusion (LLIF) and percutaneous pedicle screw (PPS) and could be followed up for at least 2 years, 35 patients with a postoperative PI-LL > 10° were included in the study. The range of fusion was from the lower thoracic spine to the pelvis in all cases; the average age was 73.5 years, and the average follow-up period was 58 months. The definition of acceptable PI-LL>10° was PI-LL>10° in the standing full spine lateral radiograph immediately after surgery and sagittal vertical axis (SVA) <50 mm at the final observation. The patients were divided into group G, in which the final-SVA was <50 mm, and group P, in which the final-SVA was ≥50 mm, and the various parameters, Oswestry Disability Index (ODI), walking speed, Time Up and Go (TUG) test, and lower limb muscle strength were compared and examined.

Results: The mean age was significantly lower in group G. The mean postoperative ODI was significantly lower in group G. The mean postoperative SVA was significantly higher in group P, and there were no significant differences in the other parameters. The mean walking speed and mean TUG were significantly faster in group G, and there were no significant differences in the mean lower limb muscle strength. There was a low correlation between age and final-SVA and a moderate correlation between walking speed and final-SVA. The cut-off values for walking speed and TUG that produced a final-SVA >50 mm were 73.9 cm/s and 12.4 s, respectively, according to receiver operating characteristics analysis.

Conclusions: Walking speed were identified as conditions that could be accepted as insufficient correction after ASD surgery, suggesting the importance of compensatory ability.

Introduction: The purpose of this study is to evaluate the relationship between the axis of the humeral heads and the spinal sagittal alignment in dropped head syndrome (DHS).

Methods: Overall, 12 cases of DHS, 55 cases of cervical spondylotic myelopathy (CSM), 112 cases of lumbar canal stenosis (LCS), and 62 cases of normal volunteer (NV) were included. Standing lateral radiographs of the entire spine were obtained in position 1 (normal position) and position 2 (shoulders drawn backward to the extent possible with the elbows straightened). Shoulder incidence (SI: the angle between a line perpendicular to the upper endplate of the T1 vertebra and a line joining the center of the upper endplate of the T1 vertebra and the axis of the humeral heads, indicating the humeral head position) and the spinal sagittal alignment-related parameters were measured and compared. Correlation between SI and the spinal sagittal alignment related parameters in DHS was performed using Pearson's correlation coefficient.

Results: T1-5 kyphotic angle, SI (position 2) and the proportion of SI (position 2) over 0° in DHS were significantly larger than that in CSM, LCS, and NV. SI over 0° showed the axis of the humeral head was located forward of the middle of thoracic vertebrae. SI (position 1 and 2) correlated with T1-5 kyphotic angle in DHS.

Conclusions: The humeral head position and T1-5 kyphotic angle may play a role in the pathophysiology of DHS.

Introduction: The modified Controlling Nutritional Status (CONUT) score is calculated using laboratory values, including the serum albumin concentration, hemoglobin level, and total lymphocyte count, whereas the prognostic nutritional index (PNI) is calculated using the albumin concentration and total lymphocyte count. Both are valuable tools for nutritional assessment. One notable advantage of the modified CONUT score and PNI over other nutritional assessment methods is that they can be calculated retrospectively using only objective laboratory values. Previous studies have shown that the modified CONUT score is a useful tool to predict the prognosis and complications during hospital care. However, its use as a potential predictive marker for postoperative complications in patients with osteoporotic vertebral fracture (OVF) has been underexplored. The purpose of this study was to investigate the association between nutritional scores and postoperative complications in patients with OVF.

Methods: We included older adults diagnosed with and admitted for OVF from April 2022 to March 2023. Modified CONUT scores and PNI were calculated using the results of routine laboratory tests performed on admission.

Results: A total of 73 patients (30 men and 43 women) were evaluated. Among them, 24 had a normal nutritional status; 41 had mild malnutrition; 8 had moderate malnutrition, and none had severe malnutrition. Complications occurred in 18 of 73 cases (24.7%). The following complications occurred: delirium in nine cases, urinary tract infection in four cases, cerebral infarction in two cases, dehydration in one case, aspiration in one case, and diarrhea in one case. The complication rates were as follows: 4 of 24 (16.7%) in the group with a normal nutritional status, 11 of 42 (26.2%) in the group with mild malnutrition, and 3 of 7 (42.9%) in the group with moderate malnutrition. The cut-off values for the prediction of complications were a modified CONUT score of 3 and PNI of 45.2.

Conclusions: he nutritional indices, using the modified CONUT score and PNI, had predictive value for complications in patients with OVF.

Introduction: We proposed a bimodal artificial intelligence that integrates patient information with images to diagnose spinal cord tumors.

Methods: Our model combines TabNet, a state-of-the-art deep learning model for tabular data for patient information, and a convolutional neural network for images. As training data, we collected data on 259 spinal tumor patients (158 for schwannoma and 101 for meningioma). We compared the performance of the image-only unimodal model, the table-only unimodal model, a bimodal model using a gradient-boosting decision tree, and a bimodal model using TabNet.

Results: Our proposed bimodal model using TabNet performed best (area under the receiver-operating characteristic curve [AUROC]: 0.91) in the training data and significantly outperformed the physicians' performance. In the external validation using 62 cases from the other two facilities, our bimodal model showed an AUROC of 0.92, proving the robustness of the model.

Conclusions: The bimodal analysis using TabNet was effective for differentiating spinal tumors.