STUDY DESIGN: Prospective case series study

OBJECTIVE: To evaluate curve correctability, complications, and rate of growth following treatment.

BACKGROUND: Distraction-founded techniques such as traditionally growing rods or magnetically controlled growing rods are the almost globally accepted management patterns for early onset scoliosis. However, periodic lengthening operations are still needed. Moreover, an MCGR is difficult to contour, and implant-associated problems are common. We developed concave side apical control of the growing rod in which an additional anchor site is inserted at the apex to enhance stability and assist in the adjustment of axial deformity.

METHODS: Entirely skeletally immature early onset scoliosis (EOS) cases with a progressive curve of >40° and without bone or soft tissue weakness were appropriate for this study. Coronal Cobb angle, sagittal parameters, complications, spinal length, and reoperations were documented with at least a 3-year follow-up.

RESULTS: In this study, 15 patients were involved. The mean age was 7 years. The mean preoperative Cobb angle was 48°, which postoperatively became 12° with the percentage of coronal correction reaching 75.73%. The mean Cobb angle degrees of correction were 39°. T1–S1 height increased by 10 mm/year. Postoperative complications occurred in two cases with single rod technique and rod breakage.

CONCLUSION: The concave side apical control of the growing rod seems to be a hopeful surgical procedure for the management of EOS. Curve correctability in patients was 60% and can be sustained for a minimum of 2 years. Reoperations and complications might not be constricted, but the complication frequency looks more reasonable than in the current systems.

Background

S1–L5 transdiscal screw fixation is a direct stabilization technique used for surgical treatment of high-grade (III–IV) L5–S1 spondylolisthesis. It has not been used for nonspondylolisthetic cases or in combination with an interbody cage (IC). This study aimed to develop a novel, direct S1–L5 sacrolumbar interbody fusion (SLIF) technique, a combination of IC and sacrolumbar transdiscal screw.

Methods

SLIF was tested in cadaveric, clinical, and finite element analysis settings. Three cadaveric lumbar spines were used to test the SLIF procedure before clinical application. Eight patients underwent the SLIF procedure. Clinical outcomes were evaluated by visual analog score for leg and back pain, short form 36, Oswestry disability index, and neurological examination. CT scans of the lumbar spine were used to assess the hardware placement and subsequent fusion. Finite element analysis was performed on a healthy human CT-based L5-S1 model. Intact segment, unilateral facetectomy and discectomy, SLIF, and transforaminal lumbar interbody fusion (TLIF) procedures were compared in terms of the range of motion (ROM), von Mises stress on hardware, and shear-induced directional deformity. Additionally, the same set of tests were conducted in an osteoporotic model.

Results

Excellent hardware placement was feasible in three cadavers and eight patients. Preoperative neurological deficits improved in all patients. Statistically significant improvements were obtained on all self-reported questionnaire scores. All patients developed solid, Bridwell grade I fusions. Biomechanical testing revealed similar outcomes for TLIF and SLIF regarding the ROM. However, the screw's von Mises stress and shear-induced directional deformity were low for SLIF of healthy and osteoporotic bone.

Conclusions

SLIF is a feasible, safe, and effective L5–S1 fusion option suitable for all clinical scenarios. It provides several biomechanical advantages, yielding excellent clinical outcomes.

Objectives

For older adults, dysphagia is a serious problem that can occur after spinal cord injury (SCI), but its risk factors are unclear. This study aimed to identify risk factors for dysphagia in elderly patients (≥65 years) with cervical SCI.

Methods

This multicenter study included 707 patients with cervical SCI (mean age 75.3 years). Univariate and multivariate analyses were conducted for patient characteristics and geriatric nutritional risk index (GNRI).

Results

Dysphagia occurred in 69 patients (9.8%). The significant factors were as follows: male sex (odds ratio [OR] 3.43), GNRI <92 (1.83), dementia (2.94), fracture (3.40), complete paralysis (3.61), anterior surgery (3.74), and tracheostomy (17.06). Age was not identified as a risk factor.

Conclusions

Low GNRI before injury was one of the independent risk factors for dysphagia after geriatric cervical SCI. GNRI represents the comprehensive nutritional status of the elderly and reflects feeding function and its recovery capacity.

Background: Full endoscopic spine surgery continues to spread worldwide but has a long learning curve. Conventional endoscopy training uses live pigs or human cadavers, which has disadvantages such as high costs and limited availability. Therefore, this study aimed to develop and evaluate three-dimensional (3D) -printed models for endoscopy training.

Methods: Models for 3D printing were generated using raw imaging data from 1.0-mm slices of computed tomography scans, and each part was printed using a different colored material. The combined model was used for training as part of the full endoscopy training kit.

Results: This approach offers several advantages. First, it enables the creation of accurate disease models, such as lumbar disc herniation and other abnormalities, which are useful for both surgical training and preoperative simulations. Second, it is useful for learning surgical orientation. During surgical training, the surgical field can be viewed directly through an endoscope or with the naked eye. By using various colors, it becomes easier to recognize the orientation. Third, the amount of drilling resection can be easily confirmed, facilitating feedback. Finally, training for various surgical techniques is possible, including endoscopic holding techniques and using the endoscope's outer sheath to retract nerves. However, this approach also has some disadvantages, such as the lack of bleeding, inability to reproduce tissue hardness, and difficulty in faithfully recreating soft tissue, such as connective tissue, blood vessels, and fat. Therefore, it is difficult to reproduce the hardness of the calcified disc or disc herniation with apophyseal ring fracture. Moreover, 3D-printed models are not suitable for surgical training using the interlaminal approach because it is difficult to perform separation between the ligamentum flavum and dural matter or between the dural matter and intervertebral disc.

Conclusions: 3D-printed models are a useful complement to live pigs and human cadavers in surgical training and can reduce the time required to acquire endoscopic skills.

Introduction: Few studies have assessed the minimum clinically important difference (MCID) of each Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) domain. This study assessed MCIDs of JOABPEQ in patients with lumbar spine disease by generation.

Methods: We evaluated the JOABPEQ score of 805 consecutive patients with lumbar spine disease undergoing posterior surgery preoperatively and 1 year postoperatively. MCIDs of each JOABPEQ domain were determined using anchor- and distribution-based methods according to age. A question based on the concept of a health transition item was used as the anchor for the MCID decision.

Results: Overall, MCIDs of the JOABPEQ were 28.6 and 27.3 points for pain-related disorder and gait disturbance, respectively. The MCID for the lumbar spine dysfunction domain did not reach 0.6 over the area under the curve. Regarding the differences among generations, MCIDs of pain-related disorder and gait disturbance domains differed slightly between the elderly and middle-aged. The psychological disorder domain did not reflect clinically meaningful changes in the elderly. MCIDs of the social life disturbance domain decreased with age.

Conclusions: Focusing on achieving the ideal responsiveness of patient-reported outcomes across generations, MCIDs of the pain-related disorder and gait disturbance domains may be valuable for patients, regardless of age, when adopting the JOABPEQ for patients with lumbar spine disease undergoing surgery. This study only evaluated cases that underwent posterior lumbar surgery. Future research will necessitate conducting surveys concerning the outcomes of various treatments for lumbar spine disease.

Introduction

Percutaneous vertebral augmentation techniques, such as balloon kyphoplasty (BKP) and vertebral body stenting (VBS), are commonly used for surgical intervention in osteoporotic vertebral fractures (OVFs). However, markedly unstable OVF cases require additional fixation procedures, prompting the exploration of combined percutaneous vertebral augmentation and posterior fixation. A novel surgical approach involving percutaneous vertebral augmentation with penetrating endplate screws (PES) and downward PES, complemented by a short fusion of one above one below, was developed. This study aimed to introduce and report the preliminary outcomes of this technique based on a retrospective analysis of 20 consecutive cases in the short and medium term.

Methods

Surgical indications are a vertebral wedge angle difference of 10° or more, vertebral pedicle fractures, posterior wall fractures, and diffuse low-signal changes exceeding 50% on T1-weighted magnetic resonance imaging. The procedure is reserved for highly unstable cases following a comprehensive health assessment. The surgical technique involves prone positioning, fluoroscopy-guided percutaneous vertebral augmentation, and the use of downward PES in the cranial vertebral body and PES for the caudal vertebral body by percutaneous technique. The fixation range is one above and one below.

Results

The case series of 20 patients, with an average follow-up period of 146.9 days, demonstrates a mean surgical time of 57 min and minimal complications. The advantages of the technique are as follows: ease of performance, minimal fixation range, and time efficiency. Risks, such as potential screw loosening and the need for prolonged follow-up, are acknowledged.

Discussion

The technique represents a promising surgical approach that balances the requirements of minimally invasive intervention and relatively robust initial fixation for elderly osteoporotic patients with unstable OVFs. While short- and medium-term results are favorable, long-term observations are needed to further assess its efficacy. This novel technique has a potential to be a valuable surgical option for unstable OVFs.

Introduction: Ligamentum flavum (LF) hypertrophy is the main etiological factor in the development of lumbar spinal stenosis (LSS); however, its molecular pathology remains unclear. Histologically, LF hypertrophy is characterized by a reduction in elastic fibers and an increase in collagen fibers. We previously performed miRNA transcriptomic analysis on excised LF from elderly patients with LSS and identified the insulin receptor signaling along with TGFβ-mediated signaling as pathways involved in ligament hypertrophy. Therefore, this study aimed to investigate the involvement of endogenous insulin as a risk factor for LF hypertrophy in patients with LSS.

Methods: A total of 1,119 patients aged ≥65 years (average: 76.1 ± 5.9 years) treated for LSS including surgery and conservative treatment were analyzed. The flavum canal ratio (FCR) was calculated in the MRI cross-sectional image, and an FCR of 0.4275 or greater was defined as ligamentous stenosis according to Sakai' s criteria. Homeostatic model assessment for insulin resistance (HOMA-IR) was calculated and values ≥2.5 were indicative of insulin resistance in Japanese people.

Results: Fifty-one percent of patients with LSS exhibited LF hypertrophy, correlating with higher age, proportion of males and diabetic patients, BMI, HOMA-IR, and creatinine. Among LSS patients, 43.0% had insulin resistance, with 47.1% exhibiting LF hypertrophy and 38.6% without LF hypertrophy, with a significant difference. (p < 0.01) LSS patients with high insulin resistance also demonstrated significantly higher FCR (p < 0.05) and a higher percentage of LF hypertrophy. (p < 0.01) Conditional logistic regression analysis, adjusting for age, identified HOMA-IR as a significant factor.

Conclusions: The study establishes an association between LF hypertrophy and insulin resistance. Considering LF hypertrophy as an inflammation-triggered degeneration of elastic fibers, age-related changes in LF may underlie the basis of inflammatory aging.

Objective

Elderly patients have a higher frequency of upper cervical fractures caused by minor trauma; nevertheless, the clinical differences between mid- and lower-cervical (C6–C7) injuries are unclear. The aim of this study was to compare the epidemiology of lower- and mid-cervical injuries in the elderly.

Methods

This multicenter, retrospective study included 451 patients aged 65 years or older who had mid- or lower-cervical fractures/dislocations. Patients' demographic and treatment data were examined and compared based on mid- and lower-cervical injuries.

Results

There were 139 patients (31%) with lower-cervical injuries and 312 (69%) with mid-cervical injuries. High-energy trauma (60% vs. 47%, p = 0.025) and dislocation (55% vs. 45%, p = 0.054) were significantly experienced more often by elderly patients with lower-cervical injuries than by patients with mid-cervical injuries. Although the incidence of key muscle weakness at the C5 to T1 levels were all significantly lower in patients with lower-cervical injuries than those with mid-cervical injuries, impairments at C5 occurred in 49% of them, and at C6, in 65%. No significant differences were found in the rates of death, pneumonia, or tracheostomy requirements, and no significant differences existed in ambulation or ASIA impairment scale grade for patients after 6 months of treatment.

Conclusions

Elderly patients with lower-cervical fractures/dislocations were injured by high-energy trauma significantly more often than patients with mid-cervical injuries. Furthermore, half of the patients with lower-cervical injuries had mid-cervical level neurological deficits with a relatively high rate of respiratory complications.

Introduction

This study aimed to compare the outcomes of corrective fusion for adult spinal deformity (ASD) in older people using two different sagittal correction goals: the conventional formula of "pelvic incidence (PI) -lumbar lordosis (LL) mismatch <10°" and an undercorrection strategy based on the range of 10° ≤ PI-LL ≤ 20°.

Methods

A total of 102 consecutive patients (11 male and 91 female patients; mean age, 72.0 years) aged above 65 years with scoliosis >20° or LL <20° who had undergone long-segment fusion from the lower thoracic spine to the pelvis for ASD and had been followed-up for a minimum of two years at our institution since March 2013 were included in this retrospective study. After excluding patients with PI-LL ≤ −10° on postoperative standing radiographs, the remaining patients were divided into two groups: 31 patients with 10° ≤ PI-LL ≤ 20° (U group) and 63 patients with −10° < PI-LL < 10° (M group). Radiological and clinical outcomes were compared between the groups.

Results

The incidence of proximal junctional kyphosis and mechanical failure was not significantly different between the groups (p = 0.659 and 1.000, respectively). After excluding patients who underwent reoperation due to mechanical failure, there were no differences in the Oswestry Disability Index (ODI) and each domain of the Visual Analog Scale score, Scoliosis Research Society-22r patient questionnaire (SRS-22r), or the short form 36 health survey questionnaire at the final observation between the U (n = 27) and M (n = 57) groups. In addition, the non-inferiority and equivalence of the U group to the M group were demonstrated in all domains of the SRS-22r and ODI. Furthermore, the superiority of the U group was demonstrated by the functional domain of SRS-22r.

Conclusions

For the sagittal correction goal in corrective fusion surgery for ASD in the elderly, strict adherence to "PI-LL mismatch <10°" is not necessary and "PI-LL ≤20°" may be acceptable.

Introduction: This study investigates the outcomes of treating neglected unstable Hangman's fractures through a single-stage Anterior Cervical Discectomy and Fusion (ACDF) procedure with tricortical iliac crest bone grafts.

Methods: Five patients with neglected unstable Hangman's fractures, treated at our institution between March 2012 and March 2017, underwent C2–C3 ACDF. Functional outcomes were assessed using the Visual Analog Scale (VAS) score and Neck Disability Index (NDI), and neurological evaluation was done using the American Spinal Injury Association (ASIA) grading system. The radiological assessment included serial plain radiographs and a computed tomography scan at a 12-month follow-up.

Results: Postoperatively, C2–C3 angulation improved significantly, decreasing from 15° to 4.4°, and sagittal translation improved from 4.2 mm to 2 mm. The VAS score improved from 6.4 to 1.4 at 24 months postsurgery. Concurrently, NDI decreased from 70.4% to 14.8%. Fusion occurred in an average of 5.6 months. Neurologically, one patient improved from ASIA grade D to grade E, while the other four retained their grade E status.

Conclusion: A single-stage ACDF with autologous iliac crest bone grafts is an effective surgical option for neglected type II/IIA Hangman' s fractures, yielding satisfactory functional and radiological outcomes. This technique significantly corrects anterior translation and angulation, even in neglected cases, with the aid of intraoperative skull traction and plate reduction.

Introduction: Pedicle screws are commonly used in fixation to treat various spinal disorders. However, screw loosening is a prevalent complication, particularly in patients with osteoporosis. Various biomechanical studies have sought to address this issue, but the optimal depth and trajectory to increase the fixation strength of pedicle screws remain controversial. Therefore, a biomechanical study was conducted using finite element models.

Methods: Three-dimensional finite element models of the L3 vertebrae were developed from the preoperative computed tomography images of nine patients with osteoporosis and nine patients without who underwent spine surgery. Unicortical and bicortical pedicle screws were inserted into the center and into the anterior wall of the vertebrae, respectively, in different trajectories in the sagittal plane: straightforward, cephalad, and caudal. Subsequently, three different external loads were applied to each pedicle screw at the entry point: axial pullout, craniocaudal, and lateromedial loads. Nonlinear analysis was conducted to examine the fixation strength of the pedicle screws.

Results: Irrespective of osteoporosis, the bicortical pedicle screws had greater fixation strength than the unicortical pedicle screws in all trajectories and external loads. The fixation strength of the bicortical pedicle screws was not substantially different among the trajectories against any external loads in the nonosteoporotic vertebrae. However, the fixation strength of the bicortical pedicle screws against craniocaudal load in the cephalad trajectory was considerably greater than those in the caudal (P = 0.016) and straightforward (P = 0.023) trajectories in the osteoporotic vertebrae. However, this trend was not observed in pullout and lateromedial loads.

Conclusions: Our results indicate that bicortical pedicle screws should be used, regardless of whether the patient has osteoporosis or not. Furthermore, pedicle screws should be inserted in the cephalad trajectory in patients with osteoporosis.

Background: A halo vest is an immobilization device widely used to stabilize the cervical spine. Pain and infection at the skull pin insertion site are common complications, but skull perforation is rare, and most published studies are case reports. This study aimed to identify risk factors for skull perforation by comparing patients who did and did not develop perforation.

Methods: Overall thickness and the thicknesses of the internal and external laminae of the skull at the skull pin insertion sites were measured on cranial computed tomography scans of 66 patients fitted with a halo vest. The results were compared between patients who did and did not develop perforation.

Results: Four patients developed perforations. All patients with perforation were older women, and their external and internal laminae were significantly thinner than those of patients who did not develop perforation.

Conclusion: The reported causes of skull pin perforation include infection around the pin, osteoporosis, and an enlarged frontal sinus. However, most patients with perforation in the present study were older women, and the cause was the thinning of the external and external laminae.

Lumbar interbody fusion (LIF) is a surgical procedure for treating lumbar spinal stenosis and deformities. It removes a spinal disc and insert a cage or bone graft to promote solid fusion. Extensive research on LIF has been supported by numerous animal studies, which are being developed to enhance fusion rates and reduce the complications associated with the procedure. In particular, the anterior approach is significant in LIF research and regenerative medicine studies concerning intervertebral discs, as it utilizes the disc and the entire vertebral body. Several animal models have been used for anterior LIF (ALIF), each with distinct characteristics. However, a comprehensive review of ALIF models in different animals is currently lacking. Medium-sized and large animals, such as dogs and sheep, have been employed as ALIF models because of their suitable spine size for surgery. Conversely, small animals, such as rats, are rarely employed as ALIF models because of anatomical challenges. However, recent advancements in surgical implants and techniques have gradually allowed rats in ALIF models. Ambitious studies utilizing small animal ALIF models will soon be conducted. This review aims to review the advantages and disadvantages of various animal models, commonly used approaches, and bone fusion rate, to provide valuable insights to researchers studying the spine.

Introduction: This study aimedto measure the intraocular pressure (IOP) of patients undergoing open surgery in the supine position (control group) and spine surgery in the prone position (spine group) to clarify IOP range and change by posture, determine the risk factors for increased IOP in the prone position, and reduce visual complications after surgery in the prone position.

Methods: A prospective cohort study was conducted inhealthy adults (34–83 years of age) with an American Society of Anesthesiologists classification I/II. The spine group was examined for IOP, anterior chamber angle (ACA), and fundus findings the day prior to surgery. On the day of surgery, IOP measurements were taken at fixed time points: immediately after intubation; at 0.5, 1, and 2 h after intubation; at suture closure; and at the end of surgery in the control group. In the spine group, they were taken immediately after intubation; at 0.5, 1, and 2 h after prone position; at suture closure; and immediately and 5 min after returning to the supine position. The risk factors for increased IOP in the prone position were examined.

Results: The control group showed no significant changes in IOP within the normal range (< 20 mmHg) during surgery. In the spine group, IOP was higher at each time point than immediately after intubation. IOP increased sharply above the normal range within 1 h after changing from the supine to the prone position and continued to gradually increase until suture closure. IOP decreased 5 min after the patient returned to the supine position. ACA, body mass index, blood loss, time in the prone position, and operative time were not risk factors for increased IOP in the prone position.

Conclusions: Patients were constantly exposed to above-normal IOP during prone spinal surgery. However, neither group reported visual impairment. No risk factors were identified for increased IOP in the prone position.

Background. Human pose estimation, a computer vision technique that identifies body parts and constructs human body representations from images and videos, has recently demonstrated high performance through deep learning. However, its potential application in clinical photography remains underexplored. This study aimed to establish photographic parameters for patients with adolescent idiopathic scoliosis (AIS) using pose estimation and to determine correlations between these photographic parameters and corresponding radiographic measures.

Methods. We conducted a study involving 42 patients with AIS who had undergone spinal correction surgery and conservative treatment. Preoperative photographs were captured using an iPhone 13 Pro mounted on a tripod positioned at the head of an X-ray tube. From the outputs of pose estimation, we derived five photographic parameters and subsequently conducted a statistical analysis to assess their correlations with relevant conventional radiographic parameters.

Results. In the sagittal plane, we identified significant correlations between photographic and radiographic parameters measuring trunk tilt angles. In the coronal plane, significant correlations were found between photographic parameters measuring shoulder height and trunk tilt and corresponding radiographic measurements.

Conclusions. The results suggest that pose estimation, achievable with common mobile devices, offers potential for AIS screening, early detection, and continuous posture monitoring, effectively mitigating the need for X-ray radiation exposure. Level of Evidence: 3.

Introduction: Despite that lateral lumbar interbody fusion (LLIF) is a minimally invasive surgery, some patients complain of severe site pain immediately after the surgery. This study aimed to explore the extent of perioperative pain after LLIF, compare the degree of perioperative pain after LLIF with that after other surgical procedures, and evaluate the factors associated with severe pain in the early postoperative period.

Methods: In this study, 93 patients who underwent lumbar spine surgeries for lumbar degenerative diseases were analyzed. The patients were categorized into three groups based on the surgical procedure: Group L, LLIF with percutaneous pedicle screw (PPS); Group P, posterolateral fusion (PLF) or posterior lumbar interbody fusion (PLIF); and Group D, posterior decompression (fenestration). The extent of low back pain was evaluated using the visual analog scale (VAS) preoperatively and from postoperative days 1 to 14.

Results: The VAS score for postoperative pain decreased in a time-dependent manner in all three groups (P < 0.01). Repeated measures analysis of variance (ANOVA) showed that the VAS in Group L was significantly higher than that in Group D (P < 0.01). Time point analysis revealed that the VAS scores from postoperative days 1 to 9 in Group L were significantly higher than those in Group D (P < 0.05). No significant difference was observed in the VAS scores of postoperative pain between Groups L and P on all postoperative days. The VAS score for early postoperative pain in Group L was significantly correlated with the change in disc height index (P < 0.05, r = 0.43) and tended to be associated with the grade of preoperative disc degeneration and the VAS score of preoperative low back pain (P = 0.076–0.19).

Conclusions: This study is the first to evaluate the factors associated with pain during the early postoperative period of LLIF. Although LLIF is a minimally invasive surgery, severe pain may develop in patients with significant preoperative disc degeneration or following spinal correction surgery.

Objective. The association between postoperative patient-reported outcomes (PROs) and patient satisfaction remains poorly defined in patients undergoing surgery for thoracic myelopathy. This study aimed to investigate PROs and patient satisfaction following surgical intervention for thoracic myelopathy.

Methods. A prospective cohort of 133 patients who underwent surgery for thoracic myelopathy at 13 hospitals between April 2017 and August 2021 was enrolled. Patient demographics and perioperative complications were recorded. PROs were assessed using questionnaires administered preoperatively and 1 year postoperatively, including the EuroQol-5 dimension, physical and mental component summaries of the 12-item Short-Form Health Survey, Oswestry Disability Index, and numerical rating scales for low back, lower extremity, and plantar pain. Patients were categorized into two groups: satisfied (very satisfied, satisfied, and slightly satisfied) and dissatisfied (neither satisfied nor dissatisfied, slightly dissatisfied, dissatisfied, and very dissatisfied).

Results. The mean age of the patients was 66.5 years, comprising 87 men and 46 women. The most common diagnoses were ossification of the ligamentum flavum (48.8%) and thoracic spondylotic myelopathy (26.3%). Seventy-four (55.6%) and 59 (44.3%) patients underwent decompression surgery and underwent decompression with fusion, respectively. Eight patients required reoperation due to postoperative surgical site infection, hematoma, and insufficient decompression in four, three, and one patient. Ninety (67.7%) patients completed both the preoperative and postoperative PRO questionnaires, all of which demonstrated significant improvement. Among them, 58 (64.4%) and 32 (35.6%) reported satisfaction and dissatisfaction with their treatment, respectively. The satisfied group showed superior improvement in PROs than the dissatisfied group, although there were no significant differences in complication rates between the two groups.

Conclusions. The 64.4% satisfaction rate observed in patients undergoing surgery for thoracic myelopathy was lower than that reported in previous studies on cervical or lumbar spine surgery. The dissatisfied group exhibited significantly poorer quality of life (QOL) and higher pain scores than the satisfied group.

Introduction: Chemonucleolysis with condoliase is a minimally invasive treatment option for lumbar disk herniation (LDH). However, studies reporting the efficacy of condoliase in patients aged <20 years are scarce. Therefore, the present study aimed to evaluate the efficacy of condoliase therapy for LDH in the aforementioned population.

Methods: Condoliase administration was determined based on adequate informed consent. The study enrolled 138 patients (mean age, 41.3 ± 15.4 years) with LDH who received condoliase injections with a follow-up period of 1 year. The patients were divided into Group Y (age, <20 years) and Group A (age, 20–70 years). The clinical outcomes were visual analog scale (VAS) scores for leg and back pain and Oswestry Disability Index (ODI) values. Changes in disk height and degeneration were evaluated. These data were obtained at baseline and at the 3-month and 1-year follow-ups. Condoliase therapy was considered to be effective if it improved the VAS score for leg pain by ≥50% at 1 year from baseline and prevented surgery.

Results: Groups Y and A consisted of 15 and 123 patients, respectively. Condoliase therapy was effective in 9 patients (60.0%) in Group Y and 96 patients (78.0%) in Group A. The rates of Pfirrmann grade deterioration and recovery were substantially higher in Group Y than in Group A (83.3% vs. 45.8% and 50.0% vs. 16.3%, respectively). While the disk height reduction in Group Y was greater at 3 months, it recovered to the same level as that in Group A at 1 year. In Group Y, patients who did not respond to the treatment exhibited a considerably higher preoperative ODI (P < 0.05).

Conclusions: Chemonucleolysis with condoliase is considered to have limited efficacy in patients aged <20 years. Caution should be taken when managing cases showing lumbar instability or existing disability. While chemonucleolysis with condoliase is a less invasive treatment option for LDH, the administration should be decided upon with sufficient consent considering the potential limited efficacy and disk degeneration.

Introduction: Intradiscal condoliase injection for lumbar disc herniation (LDH) was developed in Japan in 2018. The treatment is intermediate between conservative therapy and surgery, and its frequency is increasing. Condoliase is limited to a single application over a lifetime, rendering it important to understand the indications and predictors of its effectiveness. This review aimed to summarize published studies and provide appropriate indications and limitations for appropriate patient selection based on existing findings.

Methods:While adhering to PRISMA guidelines, we searched the PubMed, Web of Science, and EMBASE databases to identify articles reporting the clinical outcomes of intradiscal condoliase injection for LDH. Data extraction focused on the effective rate, prognostic factors, and posttreatment imaging changes and was used in the meta-analysis.

Results: Nineteen studies met the inclusion criteria. Our meta-analysis revealed 78% total response, 11% posttreatment surgery, and 42% posttreatment Pfirrmann-classification-grade progression rates. Posttreatment intervertebral disc degeneration was potentially associated with an improved response rate and disc regeneration one year posttreatment, especially in young patients. The Regimen for patients aged <20 and >70 years should be carefully selected, including those with a disease duration of >1 year, recurrent LDH, small-sized LDH, vertebral instability, and inadequate duration (<3 months) of conservative therapy.

Conclusions: Although long-term outcomes and imaging changes must be evaluated owing to the heterogeneity of previous studies, intradiscal condoliase injection is a minimally invasive and cost-effective treatment option for patients with LDH. Treatment indications should be determined after carefully evaluating evidence from previous conservative and surgical treatments.

Introduction: This study aimed to investigate the relationship between childbirth and lower back pain and determine the health-related quality of life of female patients with lower back pain.

Methods: A total of 111 patients were divided into three groups: those who had given birth and developed lower back pain due to pregnancy, childbirth, or child-rearing movements (childbirth group, n = 41), those who had given birth and developed lower back pain due to other causes (childbirth and other cause group, n = 29), and those who were nulliparous (nulliparous group, n = 41). A total of 22 physical therapists evaluated the patients during initial rehabilitation. Basic information and health-related quality of life were compared among the three groups using a one-way analysis of variance for the visual analog scale scores for lower back pain, summary scores (physical health [physical component summary] and mental health [mental component summary]), and subscales (physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health) of the Short Form-8 Health Survey. These values were also compared with the national standard values for health-related quality of life. The chi-square test of independence was used to compare distributions, and Fisher' s exact probability test was used for cells with an expected value of <5.

Results: Most participants had physical component summary scores below the national standard values. The visual analog scale scores for lower back pain were significantly higher in the birth group than in the nonbirth group. The physical component summary, physical functioning, and general health scores were significantly lower in the birth group than in the nonbirth group. Moreover, bodily pain scores were significantly lower in the birth group than in the other groups.

Conclusions: For female patients with lower back pain due to pregnancy, childbirth, or childcare activities, physical conditions unique to postpartum women should be considered, and if necessary, instructions for activities of daily living should be provided.

Introduction: Anterior cervical discectomy and fusion (ACDF) has proven to be a clinically efficient and cost-effective method for treating patients with degenerative cervical spine conditions. New intervertebral implant products are being developed to improve fusion and stability while decreasing complications. This study assesses the effectiveness of Tritanium C (Tri-C) Anterior Cervical Cage (Stryker) in the treatment of degenerative disk disease (DDD) of the cervical spine compared with polyetheretherketone (PEEK) cages.

Methods: A retrospective cohort analysis was conducted using data prospectively collected from two institutions. Patients who underwent ACDFs for DDD using either the Tri-C cage or PEEK cage were identified. The patients' demographics, comorbidities, operative variables, and baseline patient-reported outcomes (PROs) were collected. PROs included the Neck Disability Index (NDI) and numeric rating scale (NRS) for neck and arm pain. The primary outcomes included 3- and 12-month PROs as well as the rates of 90-day readmission, 90-day reoperation, and perioperative complication. The radiographic outcomes included rates of subsidence, cage movement, and successful fusion within 12 months. Multivariate linear regression models were run to identify variables predictive of 12-month PROs.

Results: A total of 275 patients who underwent ACDF were included in this study and were divided into two groups: PEEK (n = 213) and Tri-C (n = 62). Both groups showed improvement in neck and arm pain and NDI postoperatively. When Tri-C and PEEK were compared, no significant differences were observed in the 3- or 12-month changes in neck or arm pain or NDI. Furthermore, there were no differences in the rates of 90-day readmission, 90-day reoperation, and perioperative complication. Regression analysis revealed that Tri-C vs. PEEK was not a significant predictor of any outcome.

Conclusions: Our results indicate that the use of porous titanium Tri-C cage during ACDFs is an effective method for managing cervical DDD in terms of PROs, perioperative morbidity, and radiologic parameters. No significant difference was observed in any clinical outcome between patients undergoing ACDF using the Tri-C cage and those in whom the PEEK cage was used.

Objectives

We aimed to implement the enhanced recovery after surgery (ERAS) protocol for pediatric neuromuscular scoliosis (NMS) surgery and to examine the effectiveness of this program in this study.

Methods

Subjects were children with NMS who underwent scoliosis surgery at our department by a surgeon using a single posterior approach. A series of 27 cases before the introduction of ERAS and 27 cases during program stabilization were included in the study. Patient backgrounds did not show significant differences before and after introducing ERAS. Perioperative data, complications, length of hospital stay (LOS), and readmission within 90 days were investigated and statistically analyzed.

Results

When the pre- and post-ERAS induction groups were compared, no significant differences in anesthesia induction time (p = 0.979), pelvic fixation (p = 0.586), fusion levels (p = 0.479), intraoperative hypothermia duration (p = 0.154), end-of-surgery body temperature (p = 0.197), operative time (p = 0.18), postoperative main Cobb angle (p = 0.959), main Cobb angle correction rate (p = 0.91), postoperative spino-pelvic obliquity (SPO) (p = 0.849), and SPO correction rate (p = 0.267) were observed. However, significant differences in using V-flap technique (p = 0.041), intraoperative blood loss (p = 0.001), and LOS (p = 0.001) were observed. Intraoperative blood loss was weakly correlated with LOS (p = 0.432 and 0.001). No statistically significant difference existed between the V-flap method and LOS (p = 0.265). Multiple regression analysis using LOS as the objective variable and ERAS protocols and intraoperative blood loss as explanatory variables revealed that the effect of ERAS on LOS was greater than that of intraoperative blood loss. No statistically significant differences in the readmission rates within 90 days were found.

Conclusion

After the introduction of ERAS, LOS decreased without an increase in complications or readmissions within 90 days.

Background: The Scoliosis Research Society-30 (SRS-30) is a questionnaire originally developed from the SRS-22r questionnaire and is used to evaluate adolescent idiopathic scoliosis (AIS). It comprised questions on five domains: function, pain, self-image, mental health, and satisfaction, with seven additional questions related to postoperative aspects. In addition to the original English version, translations in multiple languages have been effectively applied. Herein, we evaluated the internal consistency and external validity of the Japanese version of the SRS-30 for AIS patients.

Methods: Among the 30 questions in SRS-30, the eight additional questions from SRS-22r were translated and back-translated to create a Japanese version of the SRS-30. This translated questionnaire was then used to survey patients with AIS who underwent corrective fusion surgery one year postoperatively. The internal consistency of the responses was evaluated using the Cronbach α coefficient. Additionally, the Spearman correlation analyses were conducted to assess the correlation between the scores obtained from the SRS-30 Japanese version and SRS-22r and the Oswestry Disability Index (ODI) for the overall scale and the five domains.

Results: A total of 81 cases (eight males and 73 females; mean age at surgery 14.4 years) were enrolled. The mean preoperative Cobb angle was 51.0°. The Cronbach α coefficient for the overall SRS-30 was 0.861, indicating high internal consistency, while the coefficients for each domain were as follows: function/activity, 0.697; pain, 0.405; self-image/appearance, 0.776; mental health, 0.845; and satisfaction, 0.559. The SRS-30 total score significantly correlated with the SRS-22r total (r = 0.945, P < 0.001) and the ODI (r = −0.511, P < 0.001). The SRS-30 domains highly correlated with the corresponding SRS-22r domains, with correlations ranging from r = 0.826 to 0.901 (all P < 0.001).

Conclusions: The Japanese version of the SRS-30 demonstrated good internal and external validity. The SRS-30 can be used as an assessment tool for health-related quality of life in AIS patients.

Numerous studies have explored the connection between lumbar osteophytes, their pathophysiology, and instability since Macnab's 1971 report on traction spurs as an indicator of lumbar instability. This study provides a narrative historical overview of traction spurs, a classic finding that suggests lumbar instability. It summarizes the causes of anterior lumbar vertebral osteophytes, the relationship between traction spurs and lumbar spinal instability, and the clinical significance of traction spurs. Vertebral osteophytes are grouped into two categories, namely, traction spurs or claw spurs, which represent different stages of the same pathological process. Traction spurs are indicative of instability and occur in the early stage of disc degeneration, characterized by temporary dysfunction or instability. Traction spur formation following fusion surgery can predict union or nonunion, and it serves as an indicator of preoperative and postoperative segmental instability. The relationship between traction spurs and radiographic instability, as well as their association with imaging findings such as CT and MRI, has been clarified. Additionally, finite element analysis and mechanical testing have been used to investigate the significance of traction spurs. However, further research is needed to verify that traction spurs are an accurate indicator of pre- and postoperative lumbar instability.

Introduction: Segmental spinal deformity results from vertebral compression fracture (VCF) and progressive collapse of the fractured vertebral body (VB). The VB stenting (VBS) system^® comprises a balloon-assisted, expandable, intrasomatic, metal stent that helps maintain the restored VB during balloon removal and cement injection, which minimizes cement leakage. We performed a prospective, multicenter, clinical trial of the VBS system in Japanese patients with acute VCF owing to primary osteoporosis.

Methods: Herein, 88 patients, 25 men and 63 women aged 77.4 ± 8.3 years, with low back pain, numerical rating scale (NRS) score of ≥4, and mean VB compression percentage (VBCP) of <60% were enrolled. The primary endpoints were the VBCP restoration rate and reduction in low back pain 1 month and 7 days after VBS surgery, respectively. Secondary endpoints included changes in VBCP, NRS pain score, Beck index, kyphosis angle, and quality of life according to the short form 36 (v2) score. Safety was assessed as adverse events, device malfunctions, and new vertebral fractures.

Results: Overall, 70 patients completed the study. VBS surgery increased the restoration rates of anterior and midline VBCP by 31.7% ± 26.5% (lower 95% confidence intervals (CI): 26.8) and 31.8% ± 24.6% (lower 95% CI: 27.2), respectively, and the reduction in NRS pain score was −4.5 ± 2.4 (upper 95% CI: −4.0). As these changes were greater than the predetermined primary endpoint values (20% for VBCP and −2 for NRS score), they were judged clinically significant; these changes were maintained throughout the 12-month follow-up (p < 0.001). Likewise, significant improvement was observed in the Beck index, kyphosis angle, and quality of life score, which were maintained throughout the follow-up. There were three serious adverse events. New fractures occurred in 12 patients—all in the adjacent VB.

Conclusions: VBS surgery effectively restored the collapsed VB, relieved low back pain, and was tolerable in patients with acute osteoporotic VB fracture.

Background: Precise prediction of hospital stay duration is essential for maximizing resource utilization during surgery. Existing lumbar spinal stenosis (LSS) surgery prediction models lack accuracy and generalizability. Machine learning can improve accuracy by considering preoperative factors. This study aimed to develop and validate a machine learning-based model for estimating hospital stay duration following decompression surgery for LSS.

Methods: Data from 848 patients who underwent decompression surgery for LSS at three hospitals were examined. Twelve prediction models, using 79 preoperative variables, were developed for postoperative hospital stay estimation. The top five models were chosen. Fourteen models predicted prolonged hospital stay (≥14 days), and the most accurate model was chosen. Models were validated using a randomly divided training sample (70%) and testing cohort (30%).

Results: The top five models showed moderate linear correlations (0.576–0.624) between predicted and measured values in the testing sample. The ensemble of these models had moderate prediction accuracy for final length of stay (linear correlation 0.626, absolute mean error 2.26 days, standard deviation 3.45 days). The c5.0 decision tree model was the top predictor for prolonged hospital stay, with accuracies of 89.63% (training) and 87.2% (testing). Key predictors for longer stay included JOABPEQ social life domain, facility, history of vertebral fracture, diagnosis, and Visual Analogue Scale (VAS) of low back pain.

Conclusion: A machine learning-based model was developed to predict postoperative hospital stay after LSS decompression surgery, using data from multiple hospital settings. Numerical prediction of length of stay was not very accurate, although favorable prediction of prolonged stay was accomplished using preoperative factors. The JOABPEQ social life domain score was the most important predictor.

Introduction: Recently, patient satisfaction has gained prominence as a crucial measure for ensuring patient-centered care. Furthermore, patient satisfaction after lumbar spinal canal stenosis (LCS) surgery is an important metric for physician's decision of surgical indication and informed consent to patient. This study aimed to elucidate how patient satisfaction changed after LCS surgery to identify factors that predict patient dissatisfaction.

Methods: We retrospectively reviewed time-course data of patients aged ≥40 years who underwent LCS surgery at multiple hospitals. The participants completed the Zurich Claudication Questionnaire (ZCQ) and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) before surgery and then 6 months and 1 year postsurgery. Patient satisfaction was categorized according to the postoperative score of the satisfaction domain of the ZCQ: satisfied, score ≤ 2.0; moderately satisfied, 2.0 < score ≤ 2.5; and dissatisfied, score > 2.5.

Results: The study enrolled 241 patients. Our data indicated a satisfaction rate of around 70% at 6 months and then again 1 year after LCS surgery. Among those who were dissatisfied 6 months after LCS surgery, 47.6% were more satisfied 1 year postsurgery. Furthermore, 86.2% of those who were satisfied 6 months after LCS surgery remained satisfied at 1 year. Multivariable analysis revealed that age (relative risk, 0.5; 95% confidence interval, 0.2–0.8) and preoperative score of psychological disorders on the JOABPEQ (relative risk, 0.2; 95% confidence interval, 0.03–0.08) were significantly associated with LCS surgery dissatisfaction. In addition, the receiver operating characteristic curve analysis revealed that the cutoff value for the preoperative score of psychological disorder of the JOABPEQ was estimated at 40 for LCS surgery dissatisfaction.

Conclusions: Age and psychological disorders were identified as significant predictors of dissatisfaction, with a JOABPEQ cutoff value providing potential clinical applicability.

Introduction

Postoperative spinal epidural hematoma (PSEH) is a severe complication of spinal surgery that necessitates accurate and timely diagnosis. This study aimed to assess the accuracy of ultrasonography as an alternative diagnostic tool for PSEH after microendoscopic laminotomy (MEL) for lumbar spinal stenosis, comparing it with magnetic resonance imaging (MRI).

Methods

A total of 65 patients who underwent MEL were evaluated using both ultrasound- and MRI-based classifications for PSEH. Intra- and interrater reliabilities were analyzed. Furthermore, ethical standards were strictly followed, with spine surgeons certified by the Japanese Orthopaedic Association performing evaluations.

Results

Among the 65 patients, 91 vertebral segments were assessed. The intra- and interrater agreements for PSEH classification were almost perfect for both ultrasound (κ = 0.824 [95% confidence interval (CI) 0.729–0.918] and κ = 0.810 [95% CI 0.712–0.909], respectively) and MRI (κ = 0.839 [95% CI 0.748–0.931] and κ = 0.853 [95% CI 0.764–0.942], respectively). The results showed high concordance between ultrasound- and MRI-based classifications, validating the reliability of ultrasound in postoperative PSEH evaluation.

Conclusions

This study presents a significant advancement by introducing ultrasound as a precise and practical alternative to MRI for PSEH evaluation. The comparable accuracy of ultrasound to MRI, rapid bedside assessments, and radiation-free nature make it valuable for routine postoperative evaluations. Despite the limitations related to specific surgical contexts and clinical outcome assessment, the clinical potential of ultrasound is evident. It offers clinicians a faster, cost-effective, and repeatable diagnostic option, potentially enhancing patient care. This study establishes the utility of ultrasound in evaluating postoperative spinal epidural hematomas after MEL. With high concordance to MRI, ultrasound emerges as a reliable, practical, and innovative tool, promising improved diagnostic efficiency and patient outcomes. Further studies should explore its clinical impact across diverse surgical scenarios.

Introduction: Studies describing the relationship between the hip and spine have reported that corrective spinal surgery for adult spinal deformity (ASD) affects the orientation of the acetabulum. However, the extent to which spinal correction in ASD affects acetabular anteversion in the standing position is unclear, especially after total hip arthroplasty, for which dislocation is a concern. The purpose of this study was to evaluate changes in anterior acetabular coverage in the upright position due to extensive correction surgery for ASD.

Methods: Thirty-six consecutive patients who had undergone spinal corrective surgery from the thoracolumbar region to the pelvis were enrolled and evaluated. The ventral–central–acetabular (VCA) angle and anterior acetabular head index (AAHI) were measured with a false-profile view to evaluate the relationship between acetabular anteversion in the standing position and spinopelvic parameters before and after surgery. The spinopelvic parameters measured included thoracic kyphosis, pelvic incidence, pelvic tilt (PT), sacral slope, lumbar lordosis (LL), sagittal vertical axis, and global tilt.

Results: The VCA angle and AAHI were significantly increased after spinal deformity correction (p < 0.001). The changes in LL and PT were correlated with the VCA angle (LL: right, ρ = 0.56; left, ρ = 0.55, p < 0.001; PT: right, ρ = −0.59; left, ρ = −0.64, p < 0.001) and AAHI (LL: right, ρ = 0.51; left, ρ = 0.58, p < 0.01; PT: right, ρ = −0.52; left, ρ = −0.59, p < 0.01), respectively. Linear regression analysis revealed that a 10° increase in LL results in 1.4°–1.9° and 1.6%–2% increases in the VCA angle and AAHI, respectively.

Conclusions: Surgical correction for ASD significantly affects sagittal spinopelvic parameters, resulting in increased acetabular anteversion. The anterior coverage of the acetabulum in the postoperative standing position could be predicted with the intraoperatively measured LL, and evaluation using a false-profile was considered useful for treating ASD, particularly in patients after total hip arthroplasty.

Purpose

To analyze the reliability of the newly developed patient-specific Screw Guide Template (SGT) system as an intraoperative navigation device for spinal screw insertion.

Methods

We attempted to place 428 screws for 51 patients. The accuracy of the screw track was assessed by deviation of the screw axis from the preplanned trajectory on postoperative CT. The safety of the screw insertion was evaluated by the bone breach of the screw. The bone diameter available for screw trajectory (DAST) was measured, and the relations to the bone breach were analyzed.

Results

In the inserted screws, 98.4% were defined as accurate, and 94.6% were contained in the target bone. In the cervical spine, the screw deviation between breaching (0.57 mm) and contained screws (0.43 mm) did not significantly differ, whereas DAST for breaching screws (3.62 mm) was significantly smaller than contained screws (5.33 mm) (p < 0.001). Cervical screws with ≥4.0 mm DAST showed a significantly lower incidence of bone breach (0.4%) than ≤3.9 mm DAST (28.3%) (p < 0.001). In the thoracic spine, screw deviation and DAST had significant differences between breaching (1.54 mm, 4.41 mm) and contained (0.75 mm, 6.07 mm) (p < 0.001). The incidence of the breach was significantly lower in thoracic screws with ≥5.0 mm (1.9%) than ≤4.9 (21.9%) DAST (p < 0.001).

Conclusions

This study demonstrated that our SGT system could support precise screw insertion for 98.4% accuracy and 94.6% safety. DAST was recommended to be ≥4.0 and ≥5.0 mm in the cervical and thoracic spines for safe screw insertion.

Introduction: The incidence of hyponatremia after orthopedic surgery is high. Hyponatremia may prolong hospitalization and increase mortality, but few reports have identified risk factors for hyponatremia after spinal surgery. This study aims to determine the incidence and risk factors for hyponatremia after spinal surgery.

Methods: A total of 200 patients aged 20 years or older who underwent spinal surgery at our hospital from 2020–2021 were recruited. Data on age, sex, height, weight, body mass index, operation duration, blood loss, albumin level, the geriatric nutritional risk index (GNRI), potassium level, the estimated glomerular filtration rate (eGFR), sodium level, length of hospital stay, history of hypertension, dialysis status, the occurrence of delirium during hospital stay, and oral medication use were collected. Comparisons between the postoperative hyponatremia group and the postoperative normonatremia group were conducted to evaluate the impact of hyponatremia on clinical outcomes.

Results: Postoperative hyponatremia was observed in 56 (28%) of the 200 patients after spinal surgery. Comparison between the postoperative hyponatremia group with the postoperative normonatremia group revealed that the patients in the postoperative hyponatremia group were significantly older (72 versus 68.5 years, p < 0.01). Postoperative hyponatremia was significantly associated with low GNRI values (100.8 versus 109.3, p < 0.01), low eGFR values (59.2 versus 70.8 mL/min/1.73 m², p < 0.01), preoperative hyponatremia (138.5 vs. 141 mEq/L, p < 0.01), and a high incidence of delirium (12.5% versus 2.7%, p = 0.01). Older age (odds ratio = 1.04, p = 0.01) and preoperative hyponatremia (odds ratio = 0.66, p value < 0.01) were risk factors for postoperative hyponatremia.

Conclusions: In addition to older age and preoperative hyponatremia, the study identified new risk factors for postoperative hyponatremia, which are preoperative undernutrition and impaired renal function. The incidence of delirium was significantly higher in the postoperative hyponatremia group, suggesting that correcting preoperative hyponatremia and ensuring good nutrition may prevent delirium and thereby shorten hospital stays.

Introduction: Locomotive syndrome caused by degenerative musculoskeletal diseases is reported to improve with surgical treatment. However, it is unclear whether surgical treatment is effective for the locomotive syndrome developing in patients with degenerative cervical myelopathy (DCM). Thus, this study primarily aimed to longitudinally assess the change in locomotive syndrome stage before and after cervical spinal surgery for patients with DCM using the 25-question geriatric locomotive function scale (GLFS-25). A secondary objective was to identify factors associated with the postoperative improvement in the locomotive syndrome stage.

Methods: We retrospectively reviewed clinical data of patients undergoing cervical spine surgery at our institution from April 2020 to May 2022 who had answered the Japanese Orthopaedic Association Cervical Myelopathy Assessment Questionnaire, visual analog scale, and GLFS-25 preoperatively and at 6 months and 1 year postoperatively. We collected demographic data, medical history, preoperative radiographic parameters, presence or absence of posterior longitudinal ligament ossification, and surgical data.

Results: We enrolled 115 patients (78 men and 37 women) in the present study. Preoperatively, using the GLFS-25, 73.9% of patients had stage 3, 10.4% had stage 2, 9.6% had stage 1, 6.1% had no locomotive syndrome. The stage distribution of locomotive syndrome improved significantly at 6-months and 1-year postoperatively. The multivariable Poisson regression analysis revealed that better preoperative lower extremity function (relative risk: 3.0; 95% confidence interval: 1.01–8.8) was significantly associated with postoperative improvement in the locomotive syndrome stage.

Conclusions: This is the first study to longitudinally assess the locomotive syndrome stage in patients with DCM using GLFS-25. Our results indicated that patients with DCM experienced significant improvement in the locomotive syndrome stage following cervical spine surgery. Particularly, the preoperative lower extremity function was significant in postoperative improvement in the locomotive syndrome stage.

Introduction: Previous research has demonstrated that mid- to long-term health-related quality of life following corrective fusion surgery for adult spinal deformity (ASD) can be improved by appropriate revision surgery. In this study, we aim to compare the cost-effectiveness of corrective fusion surgery for ASD with and without unexpected revision surgery 5 years postoperatively.

Methods: In total, 79 patients with ASD (mean age, 68.7 years) who underwent corrective fusion surgery between 2013 and 2015 were included in this study. Cost-effectiveness was evaluated based on the cost of obtaining 1 quality-adjusted life year (QALY). Patients were divided into two groups according to the presence or absence of unexpected revision surgery following corrective fusion and were subjected for comparison.

Results: As per our study findings, 26 (33%) of the 79 ASD patients underwent unexpected revision surgery during the first 5 years following surgery. Although there was no significant difference in terms of inpatient medical costs at the time of initial surgery for 5 years after surgery between the two groups (no-revision group, revision group; inpatient medical costs at the time of initial surgery: USD 69,854 vs. USD 72,685, P = 0.344), the total medical expenses up to 5 years after surgery were found to be higher in the revision group (USD 72,704 vs. USD 104,287, P < 0.001). The medical expenses required to improve 1 QALY 5 years after surgery were USD 178,476 in the no-revision group, whereas it was USD 222,081 in the revision group.

Conclusions: Although the total medical expenses were higher in the revision group, no significant difference was observed in the cumulative QALY improvement between the revision and no-revision groups. Moreover, the medical expenses required to improve 1 QALY were higher in the revision group, with a difference of approximately 20%.

Objectives: Guidelines published in 2013 recommend early closed reduction for cervical spine dislocation. There are two types of closed reduction: manual reduction and traction. Manual reduction can be performed early. In addition, it can correct rotation and requires a short time for complete reduction. We perform manual reduction for cervical spine dislocation. This study aimed to evaluate early manual reduction's success rate and safety for cervical dislocation. We also examined the relationship between time to reduction and improvement in paralysis.

Methods: This retrospective cohort study included 361 patients with cervical spine injuries treated at our hospital between July 2010 and December 2021. We assigned patients to the early group if the time from injury to reduction was ≤6 hours and to the late group if >6 hours. We performed awake manual reduction on the patients. Furthermore, we compared reduction's success rate and safety, including neurological outcomes.

Results: Overall, 46 patients were included in the study: 31 and 15 in the early and late groups, respectively. The success rate of reduction was 93%, and no neurological complications from reduction were observed. The neurological outcomes and reduction success rates were significantly superior in the early group than in the late group.

Conclusions: Neurological outcomes were significantly superior when reduction was performed within 6 hours than after 6 hours. Manual reduction can be performed early, safely, and easily. It is effective for cervical spine dislocation requiring early reduction for an excellent neurologic prognosis.

Introduction In this study, we aim to describe the radiological characteristics of degenerative cervical kyphosis (DCK) with cervical spondylotic myelopathy (CSM) and discuss the relationship between DCK and the pathogenesis of spinal cord dysfunction.

Methods In total, 90 patients with CSM hospitalized in our center from September 2017 to August 2022 were retrospectively examined in this study; they were then divided into the kyphosis group and the nonkyphosis group. The patients' demographics, clinical features, and radiological data were obtained, including gender, age, duration of illness, cervical Japanese Orthopaedic Association (JOA) score, cervical lordosis (CL), height of intervertebral space, degree of wedging vertebral body, degree of osteophyte formation, degree of disc herniation, degree of spinal cord compression, and anteroposterior diameter of the spinal cord. In the kyphosis group, kyphotic segments, apex of kyphosis, and segmental kyphosis angle were recorded. Radiological characteristics between the two groups were also compared. Correlation analysis was performed for different spinal cord compression types.

Results As per our findings, the patients in the kyphosis group showed more remarkable wedging of the vertebral body, more severe anterior compression of the spinal cord, and a higher degree of disc herniation, while the posterior compression of the spinal cord was relatively mild when compared with the nonkyphosis group. CL was related to the type of spinal cord compression, as cervical kyphosis is an independent risk factor for anterior spinal cord compression.

Conclusion DCK might play a vital role in the pathogenesis of spinal cord dysfunction. In patients with DCK, it was determined that the anterior column is less supported, and more severe anterior spinal cord compression is present. The anterior approach is supposed to be preferred for CSM patients with DCK.

Purpose:

Tranexamic acid (TXA) has gained popularity in spinal surgery because of its potential to reduce blood loss. However, concerns regarding its safety and efficacy remain.

This systematic review and meta-analysis aimed to evaluate the efficacy of TXA in reducing blood loss and its safety profile in spinal surgeries.

Methods:

A comprehensive search was conducted in electronic databases for randomized controlled trials and prospective studies evaluating the use of TXA in spinal surgery. The primary outcomes were intraoperative and total estimated blood loss (EBL), and the secondary outcomes included the incidence and types of complications associated with TXA use. Meta-analyses were performed using random-effects models.

Results:

Thirteen studies involving 1,213 participants were included in the meta-analysis. The use of TXA was associated with significant reductions in both intraoperative (mean difference: −46.56 mL [−73.85, −19.26], p < 0.01]) and total EBL (mean difference: −210.17 mL [−284.93, −135.40], p < 0.01) while also decreasing the need for blood transfusions (risk ratio: 0.68 [0.51, 0.90], p < 0.01). No significant difference was found in the incidence and types of thrombotic complications when TXA was used in spinal surgery. Subgroup analysis showed consistent results in instrumentation and fusion surgery and different doses of TXA.

Conclusions:

TXA is effective in reducing intraoperative and overall blood loss in spinal surgery without increasing the risk of complications. These findings support the use of TXA to improve patient outcomes. However, caution should be exercised because of the heterogeneity among the included studies. Further research is needed to confirm these findings and explore potential long-term complications.

The major symptoms of lumbar disc herniation (LDH) are low back pain, radiative lower extremity pain, and lower limb movement disorder. Patients with LDH suffer from great distress in their daily life accompanied by severe economic hardship and difficulty in self-care, with an increasing tendency in the aging population. PubMed and the Cochrane Central Register of Controlled Trials were searched for relevant studies of spontaneous resorption or regression in LDH after conservative treatment and for other potential studies, which included those from inception to June 30, 2023. The objective of this narrative review is to summarize previous literatures about spontaneous resorption in LDH and to discuss the mechanisms and influencing factors in order to assess the probability of spontaneous resorption by conservative treatment. Spontaneous resorption without surgical treatment is influenced by the types and sizes of the LDH, inflammatory responses, and therapeutic factors. If the lumbar disc herniated tissue comprises a higher percentage of cartilage or modic changes have been shown on magnetic resonance imaging (MRI), resorption in LDH is prevented. The bull' s eye sign on enhanced MRI, which is a ring enhancement around a protruding disc, is a vital indicator for easy reabsorption. In addition, the type of extrusion and sequestration in LDH could forecast the higher feasibility of natural reabsorption. Moreover, the higher the proportion of protrusion on the intervertebral disc tissue within the spinal canal, the greater the likelihood of reabsorption. Therefore, which illustrates the feasibility of conservative treatments for LDH. Nonsurgical management of LDH with clinical symptoms is recommended by the authors.

The incidence of spontaneous or primary spondylodiscitis has been increasing over the years, affecting the aging population with multiple comorbidities. Several conditions influencing treatment outcomes stand out, such as diabetes mellitus, renal insufficiency, cardiovascular and respiratory dysfunction, and malnutrition. Due to these, the question arises regarding properly managing their current conditions and pre-existing disease states. Treatment plans must consider all concomitant comorbidities rather than just the infectious process. This can be done with the help of multidisciplinary teams to provide comprehensive care for patients with pyogenic spondylodiscitis. To date, there is no article regarding comprehensive medicine for spontaneous pyogenic spondylodiscitis; hence, this paper reviews the evidence available in current literature, recognizes knowledge gaps, and suggests comprehensive care for treating patients with spinal infections.

Pre-requisites for implementing multidisciplinary teams include leadership, administrative support, and team dynamics. This group comprises an appointed leader, coordinator, and different subspecialists, such as orthopedic surgeons, infectious disease specialists, internists, rehabilitation doctors, psychiatrists, microbiologists, radiologists, nutritionists, pharmacologists, nurses, and orthotists working together with mutual trust and respect.

Employing collaborative teams allows faster time for diagnosis and improves clinical outcomes, better quality of life, and patient satisfaction. Forefront communication is clear and open between all team members to provide holistic patient care. With these in mind, the need for employing multidisciplinary teams and the feasibility of its implementation emerges, showing a promising and logical path toward providing comprehensive care in managing multimorbid patients with pyogenic spondylodiscitis.

Background: Idiopathic spinal cord herniation (ISCH) is a rare condition that is characterized by ventral herniation of the spinal cord through a defect in the dura mater into the epidural space, with no identifiable cause. ISCH is frequently underdiagnosed, and the information available in case reports is limited. To provide an overview of the clinical manifestations and diagnosis of this condition, this study aims to conduct a review of reported cases of ISCH.

Methods: A literature review was carried out using seven databases. The search was conducted using the keywords "Idiopathic spinal cord herniation" OR "Idiopathic Ventral Spinal Cord Herniation" AND "Case report" OR "case series."

Results: A total of 92 relevant papers reporting 224 cases, besides the index case, were determined. Of the cases, 58.5% were females and the mean age was 50.7 (SD 13.2) years. Symptoms, diagnoses, and outcomes were similar between genders. The most common clinical signs included motor symptoms (82.6%), instability (61.3%), hypoesthesia (59.2%), and disturbance of thermal sensitivity (47.3%). Brown–Séquard syndrome was observed in 27.2% of the cases, and surgical treatment was employed in 89.7% of the cases.

Conclusion: ISCH is a pathology that is principally treated with surgical approach. This study provides valuable insights into the clinical manifestations and diagnosis of ISCH, which can aid in the early recognition and treatment of this rare condition.