Coronavirus disease 2019 (COVID-19) outbreak is an ongoing pandemic that has shocked the world. It has brought severe socioeconomic disruptions on a global scale that is unprecedented. On the frontline, the medical world is facing mounting pressure and challenges to clinical work. During this escalating worldwide crisis, spine care providers around the world are needing accurate and precise information on how surgical safety for themselves and the patients can be ensured. With the ultimate objective of formulating a standardized work process for spine practices, this article aimed to summarize some key principles from various international recommendations/consensus and combined evidence- and experience-based practice from medical communities around the world.

Introduction: Osteoporotic vertebral fracture (OVF) is the most common osteoporotic fracture, and some patients require surgical intervention to improve their impaired activities of daily living with neurological deficits. However, many previous reports have focused on OVF around the thoracolumbar junction, and the surgical outcomes of lumbar OVF have not been thoroughly discussed. We aimed to investigate the surgical outcomes for lumbar OVF with a neurological deficit.

Methods: Patients who underwent fusion surgery for thoracolumbar OVF with a neurological deficit were enrolled at 28 institutions. Clinical information, comorbidities, perioperative complications, Japanese Orthopaedic Association scores, visual analog scale scores, and radiographic parameters were compared between patients with lower lumbar fracture (L3-5) and those with thoracolumbar junction fracture (T10-L2). Each patient with lower lumbar fracture (L group) was matched with to patients with thoracolumbar junction fracture (T group).

Results: A total 403 patients (89 males and 314 females, mean age: 73.8 ± 7.8 years, mean follow-up: 3.9 ± 1.7 years) were included in this study. Lower lumbar OVF was frequently found in patients with lower bone mineral density. After matching, mechanical failure was more frequent in the L group (L group: 64%, T group: 39%; p < 0.001). There was no difference between groups in the clinical and radiographical outcomes, although the rates of complication and revision surgery were still high in both groups.

Conclusions: The surgical intervention for OVF is effective in patients with myelopathy or radiculopathy regardless of the surgical level, although further study is required to improve clinical and radiographical outcomes.

Level of evidence: Level III

Introduction: Chronic low back pain (CLBP) is a major health burden worldwide and requires patient satisfaction with treatment. Consultation length can be an important factor in patient satisfaction, but few studies have investigated the impact of consultation length on satisfaction in patients with CLBP. This study tried to elucidate the impact of consultation length on clinical outcomes in patients with CLBP.

Methods: This study is part of an analysis using the database of the nationwide, multicenter cohort for CLBP performed by the Project Committee of the Japanese Society for Spine Surgery and Related Research. A total of 427 patients aged 20-85 years (median age, 73.0 years; female, 58.6%) with CLBP were prospectively followed-up monthly for 6 months. Multivariable nonlinear regression analyses were performed to assess the effect of consultation length on outcome measures including subjective satisfaction score, EuroQol 5-dimension, Japanese Orthopaedic Association (JOA) score, Roland-Morris Disability Questionnaire, JOA Back Pain Evaluation Questionnaire, visual analog scale (VAS) and Medical Outcome Survey short-form 8-item health survey that evaluated at the next phase. Furthermore, we assessed whether the effect of consultation length on patient satisfaction was modified by the baseline Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP) score for patient and physician versions.

Results: VAS for CLBP was the only score that correlated significantly with consultation length (P = 0.018). Satisfaction score showed a significant positive correlation with consultation length in patients with the highest baseline BS-POP scores (P < 0.2). Moreover, consultation lengths more than 7.6 min and 15.1 min offered increase of satisfaction if patients show the highest BS-POP scores on patient and physician versions, respectively.

Conclusions: These findings suggest that a sufficiently long consultation is an important factor for subjective satisfaction in the patients with CLBP, particularly in patients with psychological problems.

Introduction: Cervical myelopathy frequently manifests as sensory disturbances, including numbness, and their distribution pattern aids in neurological level diagnosis. However, the objective assessment of sensory disturbances is challenging. In this study, we attempted to quantitatively evaluate sensory symptoms in patients with cervical myelopathy according to lesion level using PainVision^®.

Methods: Dermal sensations were evaluated in patients (n = 158) and healthy volunteers (n = 100) using PainVision^® PS-2100, which measured the current perception threshold (CPT). The results were analyzed for their correlation with magnetic resonance imaging (MRI) data, visual analog scale (VAS) scores, and patient functional status assessed by the Japanese Orthopaedic Association (JOA) and JOA Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) scores.

Results: Forearm and palm CPT values were significantly higher in patients with cervical myelopathy (both sites, P < 0.001) and were negatively correlated with the JOA score (forearm, r = −0.33; palm, r = −0.35; P < 0.001) and the JOACMEQ scores for upper extremity function (forearm, r = −0.37; palm, r = −0.39; P < 0.001), lower extremity function (forearm, r = −0.39; palm, r = −0.40; P < 0.001), and quality of life (forearm r = −0.27, P = 0.0025); however, no correlation was observed with the VAS score. Stratification of patients according to their lesion levels determined by MRI revealed that the C3/C4 subgroup had significantly higher forearm CPT values than the C4/C5 (P = 0.024) and C5/C6 (P = 0.0013) subgroups and higher palm CPT values than the C5/C6 subgroup (P = 0.009).

Conclusions: Quantitative measurements of sensory disturbances using the PainVision^® device correspond to the degree of patient functional disability and the lesion level. This indicates that both the distribution and intensity of sensory abnormalities are important for neurological level diagnosis in patients with cervical myelopathy.

Introduction: The cancer board system employed at many hospitals and treatment centers involves multidisciplinary healthcare teams, including physicians, and the timing of treatment generally follows that of a consultation model. Thus, it is difficult to detect spinal metastases using the current implementation of the cancer board system, which can lead to delays in treatment. A new multidisciplinary treatment strategy for patients with metastatic spinal tumors was designed, and 745 patients were treated based on this strategy.

Methods: In the first 5 years using the liaison treatment approach, 745 patients were diagnosed with metastatic spinal tumor. Tumors were discovered before a skeletal-related event (SRE) in 704 patients and after an SRE in 41 patients. We conducted our analysis in two patient groups: those with and without an SRE at the time of treatment initiation.

Results: In most patients, the average spinal instability neoplastic score was 5.2, which indicates that we were able to detect the spinal tumor before a significant breakdown of the spinal support system. Ninety-five percent of patients were classified according to the Frankel grade classification during their initial diagnosis, and many patients initially underwent treatment before the onset of paralysis. Of patients with an SRE, 33% were Frankel grade E, indicating that approximately half were paralyzed at initial diagnosis. The median survival duration was prolonged by approximately 9 months in patients without an SRE compared with those with an SRE.

Conclusions: Orthopedic spine surgeons are responsible for maintaining activities of daily living, improving quality of life, and prolonging life expectancy in patients with metastatic spinal tumors. The results of this study revealed that the liaison treatment system for metastatic spinal tumors has made it possible to successfully prevent SREs without neurological deficits and to prolong survival.

Introduction: Degenerative lumbar kyphoscoliosis is a serious clinical condition that affects activities of daily living. This study aimed to investigate the age-related progression of nonoperative degenerative lumbar kyphoscoliosis, to clarify its final state in elderly people, and to identify factors associated with its progression.

Methods: This retrospective longitudinal study included 115 nonoperative cases (mean age at first consultation, 70.9 years; range, 50-89 years). All were followed up for >6 years. The analysis included changes between initial and latest measurements in the coronal parameters (Cobb angle, L4 tilt angle, intervertebral angle, lateral spondylolisthesis, and C7-central sacral vertical line) and sagittal parameters (thoracic kyphosis, lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope, sagittal vertical axis, and vertebral wedging rate). Factors in scoliosis progression were investigated by analyzing the correlations between the initial parameter values and the increase in Cobb angle.

Results: Changes in the coronal parameters increased with age from 50s to 70s but decreased significantly in those aged 80s. Sagittal parameters increased by the age group, accelerating in those aged 80s, with the progression of vertebral wedging. In patients aged 50s-70s, the increase in Cobb angle correlated significantly with the initial Cobb angle, L4 tilt angle, and L4/L5 intervertebral angle. However, in the cases without initial scoliosis, the increase in Cobb angle correlated significantly only with the L4 tilt angle. There were no significant differences in any parameter according to the use of a trunk brace or medication for osteoporosis.

Conclusions: L4 tilt angle is an important factor in the progression of degenerative scoliosis. The progression of scoliosis gradually ends after the age of 80 years with the decreasing variation of L4 tilt angle, whereas kyphosis accelerates with aging, especially in those aged >80 years, with the progression of vertebral wedging.

Introduction: Falling is an age-related problem that increases with age. Compared with younger people, elderly people possess increased risk factors for falls, and falling among the elderly is associated with increased mortality. Risk factors for falls have been reported in elderly outpatients; however, whether sagittal spinal posture affect the risk of falls in community residents remains unclear. Therefore, we aimed to investigate the influence of sagittal spinal posture on the risk of falls in elderly community-dwelling people using spino-plevic sagittal parameters in a retrospective longitudinal study.

Methods: A total of 463 volunteers (96 men and 367 women; mean age, 72.8 years) who underwent a routine physical checkup were evaluated. Baseline whole spine and lower limb radiography, physical tests, bone mineral density (BMD), number of medications and comorbidities, patient-reported outcomes (PROs), and a history of falls in the previous four years period were examined.

Results: Univariate analysis revealed older age, lower height and weight, higher prevalence of vertebral fractures, higher number of medications, poor physical test scores including one-leg standing test and prone trunk extension, poor PROs, a higher sagittal vertical axis, and higher pelvic tilt (PT) as factors significantly associated with the risk of falls, and multivariate analysis revealed a higher sagittal vertical axis [odds ratio (OR), 1.08; 95% confidence interval (CI), 1.002-1.013; P = 0.02] and locomotive syndrome assessed using the 25-Question Geriatric Locomotive Function Scale score (OR, 1.028; 95% CI, 1.004-1.053; P = 0.03) to be associated with the risk of falls, independent of other factors in the univariate analysis.

Conclusions: The sagittal vertical axis was an independent risk factor for falls, and the prevalence of vertebral fractures and prone truck extension correlated with the sagittal vertical axis. Prospective and intervention studies are needed to prevent future falls in elderly community volunteers with a higher sagittal vertical axis.

Introduction: Hip dislocation rates in patients with combined total hip arthroplasty (THA) and spinal deformity fixation are significantly higher than those of THA alone. Nevertheless, there are no treatment recommendations for patients who undergo THA and require a spine deformity correction later.

Methods: Twenty-eight patients underwent spinal fixation surgery for adult spinal deformity. Sagittal spinopelvic alignment was analyzed on lateral radiographs taken preoperatively and postoperatively in the sitting and standing positions. Univariate linear regression analysis was conducted to identify the factors affecting the pelvic inclination in the sitting position after spinal fixation. Multiple regression analysis was conducted to determine the most efficient combination of radiographic parameters for predicting postoperative pelvic inclination while sitting.

Results: There were significantly weak associations between postoperative sacral slope (SS) in the sitting position and the following factors: the number of vertebral levels fused (β = 0.30, p = 0.003); the presence of sacral fixation (β = 0.22, p = 0.01); the presence of sacroiliac joint fixation (β = 0.24, p = 0.008); and preoperative SS while standing and sitting (β = 0.21, p = 0.01 and β = 0.34, p = 0.001). Postoperative lumbar lordosis (LL) while standing was strongly associated with postoperative SS in the sitting position (β = 0.67, p <.0001). The combination of postoperative LL in the standing position and preoperative SS in the sitting position was the best fit, and the adjusted R-squared was 0.82.

Conclusions: We devised a prediction formula for pelvic inclination while sitting after spinal fixation that has high predictability: postoperative SS while sitting = 11.7+ (0.4 × postoperative planned LL while standing) + (0.16 × preoperative SS while sitting). This study could be the basis for treatment recommendations for patients who have undergone THA and require a spine deformity correction later.

Introduction: Sarcopenia, a condition characterized by decreased skeletal muscle mass, has increasingly been attracting attention in Japan, which has an aged society. The association between chronic low back pain (CLBP) and muscle mass is important. This study aimed to investigate the effect of exercise therapy for CLBP with or without sarcopenia.

Methods: This study was a prospective cohort study. Patients who were aged >65 years during 2017-2018 and had CLBP, with pain lasting >12 weeks and pain intensity being ≥3, were included in the study. The patients were divided into two groups: sarcopenia (S) and nonsarcopenia (NS) groups. The numerical rating scale (NRS) for pain intensity, Roland-Morris Disability Questionnaire (RMDQ), Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), Hospital Anxiety and Depression Scale (HADS), trunk muscle strength, a European Quality of Life instrument, and an NRS of treatment satisfaction were assessed. All patients underwent a high-intensity exercise therapy during 2 weeks of hospitalization and were followed up for 1 and 3 months.

Results: Twenty-eight patients with CLBP were included. The prevalence rate of sarcopenia was 42.9%. The NRS and RMDQ scores and gait function were clinically improved at the end points in all patients with or without sarcopenia. Moreover, high treatment satisfaction was achieved. The quality of life, treatment satisfaction, psychological disorder subscale score of the JOABPEQ, and HADS score tended to be lower in the S group than in the NS group.

Conclusions: Our short-term exercise therapy was effective for low back pain, disability, and gait disturbance in elderly patients with CLBP with or without sarcopenia. However, the prevalence of sarcopenia was high in elderly patients with CLBP. Although low back pain and disability in patients in the S group were improved by exercise therapy, their quality of life and treatment satisfaction might be lower than those of patients without sarcopenia.

Introduction: Patient-specific instrumentation is an emerging technology with the promise of a better fit to patient anatomy. With the advent of deformity correction planning software, prefabricated rods can mitigate the need to bend rods in the operating room. Prefabricated rods allow the surgeon to provide a deformity correction closely in line with the surgical plan.

Methods: A retrospective chart review was completed, and all patients with Medicrea UNiD rod were included. A minimum of 3 week follow up upright 36-inch lateral radiograph was necessary for analysis. Overall 21 patients had Medicrea UNiD rods placed; four were excluded (one for cervicothoracic fusion, three for incomplete follow up). Pelvic parameters were documented from the preoperative, surgical plan, and postoperative radiographs using Surgimap (Nemaris Inc, NY). The parameters for the rods were based on the surgical plan. Paired t-tests were used to compare the preoperative, surgical plan, and postoperative pelvic parameters.

Results: Average lumbar lordosis, pelvic tilt, sacral slope, and sagittal vertical axis in preoperative radiographs were 35.12°, 24.82°, 28.65°, and 65.65 mm, respectively. In postoperative imaging, lumbar lordosis, pelvic tilt, sacral slope, and sagittal vertical axis were 57.00°, 18.00°, 35.71°, and 21.59 mm, respectively. There was a statistically significant difference in pelvic tilt, sacral slope, lumbar lordosis, and sagittal vertical axis between the preoperative film and surgical plan (p < 0.001), whereas no statistically significant difference was found between the surgical plan and postoperative pelvic parameters (p > 0.05).

Conclusions: Cases in which prefabricated rods were utilized demonstrated improved spinopelvic alignment. Additionally, there was no statistical difference between the surgical plan and postoperative imaging in terms of pelvic parameters. Future studies are needed to investigate the possible benefits of prefabricated rods.

Introduction: We have developed the single or double endplates penetrating screw (SEPS/DEPS) technique, which is a novel percutaneous pedicle screw (PPS) insertion technique suitable for osteoporotic vertebral body fracture (OVF) patients with diffuse idiopathic skeletal hyperostosis (DISH). This study aims to compare the effectiveness of this SEPS/DEPS technique with the conventional pedicle screw technique.

Methods: The screw is inserted upward from the outer caudal side of the pedicle toward the inner cranial side. Vertebrae affected with DISH were inserted with screws using the SEPS/DEPS technique, whereas non-fused vertebrae were inserted with screws using the conventional PPS technique. Twelve OVF patients with DISH were included in this study; three with SEPS/DEPS technique only and nine with a hybrid of both the DEPS and the conventional PPS techniques. As a control group, 12 OVF patients with DISH treated by conventional PPS. The rates of implant failures and of surgical complications were compared between the SEPS/DEPS group and the control group. The insertion torque was measured and compared between DEPS and conventional PPS in three hybrid patients.

Results: In the SEPS/DEPS group, 70 screws were inserted with the SEPS/DEPS technique and 56 screws were inserted with the conventional PPS technique. In the control group, 116 screws were inserted using the conventional PPS and the PS techniques. The loosening of screws was significantly less in screws inserted with the SEPS/DEPS technique (0/70 screws, 0%) than with screws inserted with the conventional technique (12/116 screws, 10.3%). The average insertion torque of DEPS was 2.25 Nm, which was 134% higher than that of conventional PPS which was 1.64 Nm (p = 0.04).

Conclusions: This novel SEPS/DEPS technique has a higher insertion torque compared with the conventional PPS techniques and demonstrated itself to be an effective option for patients with concomitant bone fragility due to DISH.

Introduction: Spinal malignant peripheral nerve sheath tumors (MPNSTs) are extremely rare. Because of vital surroundings, en bloc resection can be difficult in MPNSTs of the cervical spine. Herein, we report three cases of MPNST followed by radiotherapy or carbon ion radiotherapy (CIRT) after surgery.

Technical Note: In case 1, the patient underwent subtotal resection from both a posterior and anterior approach following by adjuvant X-ray radiotherapy. The patient died 13 years after surgery due to liver cancer unrelated to MPNST. In case 2, recurrence spread to the spinal canal in 10 months after primary CIRT. The patient underwent resection of the spinal canal lesion with the residual lesion treated by additional CIRT. Recurrence could be controlled for at least 1 year. In case 3, the patient underwent partial resection for the spinal canal lesion with the residual lesion treated by CIRT. Intradural and extradural recurrences from outside of the CIRT field were observed at 3 years after surgery.

Conclusions: Complete resection and adjuvant X-ray radiotherapy would be an effective treatment for MPNST of the cervical spine, even if en bloc resection with a wide margin is impossible. CIRT for the residual tumor after incomplete resection may have the potential to be an additional treatment option; however, further investigation is warranted.