Surgical outcomes of anterior column reconstruction for spinal fractures caused by minor trauma-preoperative examination of the number of intervertebral bone bridges is key to obtaining good bone fusion.

BACKGROUND: To achieve good bone fusion in anterior column reconstruction for vertebral fractures, not only bone mineral density (BMD) and bone metabolism markers but also lever arms due to bone bridging between vertebral bodies should be evaluated. However, until now, no lever arm index has been devised. Therefore, we believe that the maximum number of vertebral bodies that are bony and cross-linked with the contiguous adjacent vertebrae (maxVB) can be used as a measure for lever arms. The purpose of this study is to investigate the surgical outcomes of anterior column reconstruction for spinal fractures and to determine the effect of bone bridging between vertebral bodies on the rate of bone fusion using the maxVB as an indicator of the length of the lever arm. METHODS: The clinical data of 81 patients who underwent anterior column reconstruction for spinal fracture between 2014 and 2022 were evaluated. The bone fusion rate, back pain score, between the maxVB = 0 and the maxVB ≥ 2 patients were adjusted for confounding factors (age, smoking history, diabetes mellitus history, BMD, osteoporosis drugs, surgical technique, number of fixed vertebrae, materials used for the anterior props, etc.) and analysed with multivariate or multiple regression analyses. The bone healing rate and incidence of postoperative back pain were compared among the three groups (maxVB = 0, 2≦maxVB≦8, maxVB ≧ 9) and divided by the maxVB after adjusting for confounding factors. RESULTS: Patients with a maxVB ≥ 2 had a significantly higher bone fusion rate (p < 0.01) and postoperative back pain score (p < 0.01) than those with a maxVB = 0. Among the three groups, the bone fusion rate and back pain score were significantly higher in the 2≦maxVB≦8 group (p = 0.01, p < 0.01). CONCLUSIONS: Examination of the maxVB as an indicator of the use of a lever arm is beneficial for anterior column reconstruction for vertebral fractures. Patients with no intervertebral bone bridging or a high number of bone bridges are in more need of measures to promote bone fusion than patients with a moderate number of bone bridges are.

How coronal malalignment affects the surgical outcome in corrective spine surgery for adult symptomatic lumbar deformity.

PURPOSE: The importance of coronal alignment is unclear, while the importance of sagittal alignment in the treatment of adult patients with spinal deformities is well described. This study sought to elucidate the impact of global coronal malalignment (GCMA) in surgically treated adult symptomatic lumbar deformity (ASLD) patients. METHODS: A multicentre retrospective analysis of a prospective ASD database. GCMA was defined as GCA (C7PL-CSVL) ≥ 3 cm. GCMA is categorized based on the Obeid-Coronal Malalignment Classification (O-CM). Demographic, surgical, radiographic, HRQOL, and complication data were analysed. The risk for postoperative GCMA was analysed by univariate and multivariate analyses. RESULTS: Of 230 surgically treated ASLD patients, 96 patients showed GCMA preoperatively and baseline GCA was correlated with the baseline SRS-22 pain domain score (r = - 30). Postoperatively, 62 patients (27%, O-CM type 1: 41[18%], type 2: 21[9%]) developed GCMA. The multivariate risk analysis indicated dementia (OR 20.1[1.2-304.4]), diabetes (OR 5.9[1.3-27.3]), and baseline O-CM type 2 (OR 2.1[1.3-3.4]) as independent risk factors for postoperative GCMA. The 2-year SRS-22 score was not different between the 2 groups, while 4 GCMA patients required revision surgery within 1 year after surgery due to coronal decompensation (GCMA+ vs. GCMA- function: 3.6 ± 0.6 vs. 3.7 ± 0.7, pain: 3.7 ± 0.8 vs. 3.8 ± 0.8, self-image: 3.6 ± 0.8 vs. 3.6 ± 0.8, mental health: 3.7 ± 0.8 vs. 3.8 ± 0.9, satisfaction: 3.9 ± 0.9 vs. 3.9 ± 0.8, total: 3.7 ± 0.7 vs. 3.7 ± 0.7). Additionally, the comparisons of 2-yr SRS-22 between GCMA ± showed no difference in any UIV and LIV level or O-CM type. CONCLUSIONS: In ASLD patients with corrective spine surgery, GCMA at 2 years did not affect HRQOL or major complications at any spinal fusion extent or O-CM type of malalignment, whereas GCA correlated with pain intensity before surgery. These findings may warrant further study of the impact of GCMA on HRQOL in the surgical treatment of ASLD patients.

Does the degree of preoperative gait disturbance remain after tumor resection in patients with intradural extramedullary spinal cord tumors?

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: This study aimed to determine whether the degree of preoperative gait disturbance remains following surgical resection in patients with intradural extramedullary spinal cord tumors (IDEMSCTs), and to investigate any factors that may influence poor improvement in postoperative gait disturbance. SETTING: The single institution in Japan. METHODS: In total, 78 IDEMSCTs patients who required surgical excision between 2010 and 2019 were included. According to the degree of preoperative gait disturbance using modified McCormick scale (MMCS) grade, they were divided into the Mild and Severe groups. The mean postoperative follow-up period was 50.7 ± 17.9 months. Data on demographic and surgical characteristics were compared between the two groups. RESULTS: There was no significant difference in terms of age at surgery, sex, tumor size, surgical time, estimated blood loss, tumor histopathology, and postoperative follow-up period between the Mild and Severe groups. At the final follow-up, 84.6% of IDEMSCTs patients were able to walk without support. Gait disturbance improved after surgery in most of the patients with preoperative MMCS grades II-IV, but remained in approximately half of patients with preoperative MMCS grade V. Age at surgery was correlated with poor improvement in postoperative gait disturbance in the Severe group. CONCLUSIONS: Regardless of the degree of preoperative gait disturbance, it improved after tumor resection in most of the IDEMSCTs patients. However, in the preoperative MMCS grade III-V cases, older age at surgery would be an important factor associated with poor improvement in postoperative gait disturbance.

Effects of Bone Cross-Link Bridging on Fracture Mechanism and Surgical Outcomes in Elderly Patients with Spine Fractures.

STUDY DESIGN: This study adopted a cross-sectional study design. PURPOSE: This study was designed to investigate the effects of bone cross-link bridging on fracture mechanism and surgical outcomes in vertebral fractures using the maximum number of vertebral bodies with bony bridges between adjacent vertebrae without interruption (maxVB). OVERVIEW OF LITERATURE: The complex interplay of bone density and bone bridging in the elderly can complicate vertebral fractures, necessitating a better understanding of fracture mechanics. METHODS: We examined 242 patients (age >60 years) who underwent surgery for thoracic to lumbar spine fractures from 2010 to 2020. Subsequently, the maxVB was classified into three groups: maxVB (0), maxVB (2-8), and maxVB (9-18), and parameters, including fracture morphology (new Association of Osteosynthesis classification), fracture level, and neurological deficits were compared. In a sub-analysis, 146 patients with thoracolumbar spine fractures were classified into the three aforementioned groups based on the maxVB and compared to determine the optimal operative technique and evaluate surgical outcomes. RESULTS: Regarding the fracture morphology, the maxVB (0) group had more A3 and A4 fractures, whereas the maxVB (2-8) group had less A4 and more B1 and B2 fractures. The maxVB (9-18) group exhibited an increased frequency of B3 and C fractures. Regarding the fracture level, the maxVB (0) group tended to have more fractures in the thoracolumbar transition region. Furthermore, the maxVB (2-8) group had a higher fracture frequency in the lumbar spine area, whereas the maxVB (9-18) group had a higher fracture frequency in the thoracic spine area than the maxVB (0) group. The maxVB (9-18) group had fewer preoperative neurological deficits but a higher reoperation rate and postoperative mortality than the other groups. CONCLUSIONS: The maxVB was identified as a factor influencing fracture level, fracture type, and preoperative neurological deficits. Thus, understanding the maxVB could help elucidate fracture mechanics and assist in perioperative patient management.

Efficacy of a 4-Antigen Staphylococcus aureus Vaccine in Spinal Surgery: The STaphylococcus aureus suRgical Inpatient Vaccine Efficacy (STRIVE) Randomized Clinical Trial.

BACKGROUND: Staphylococcus aureus is a global pathogen that is frequently responsible for healthcare-associated infections, including surgical site infections (SSIs). Current infection prevention and control approaches may be limited, with S. aureus antibiotic resistance remaining problematic. Thus, a vaccine to prevent or reduce S. aureus infection is critically needed. We evaluated the efficacy and safety of an investigational 4-antigen S. aureus vaccine (SA4Ag) in adults undergoing elective open posterior spinal fusion procedures with multilevel instrumentation. METHODS: In this multicenter, site-level, randomized, double-blind trial, patients aged 18-85 years received a single dose of SA4Ag or placebo 10-60 days before surgery. SA4Ag efficacy in preventing postoperative S. aureus bloodstream infection and/or deep incisional or organ/space SSIs was the primary end point. Safety evaluations included local reactions, systemic events, and adverse events (AEs). Immunogenicity and colonization were assessed. RESULTS: Study enrollment was halted when a prespecified interim efficacy analysis met predefined futility criteria. SA4Ag showed no efficacy (0.0%) in preventing postoperative S. aureus infection (14 cases in each group through postoperative day 90), despite inducing robust functional immune responses to each antigen compared with placebo. Colonization rates across groups were similar through postoperative day 180. Local reactions and systemic events were mostly mild or moderate in severity, with AEs reported at similar frequencies across groups. CONCLUSIONS: In patients undergoing elective spinal fusion surgical procedures, SA4Ag was safe and well tolerated but, despite eliciting substantial antibody responses that blocked key S. aureus virulence mechanisms, was not efficacious in preventing S. aureus infection. Clinical Trials Registration. NCT02388165.

Incidence and predictive factors of shoulder imbalance after selective anterior spinal fusion surgery in Lenke type 5C adolescent idiopathic scoliosis.

Background: No study has assessed the incidence or predictors of postoperative shoulder imbalance (PSI) in patients with Lenke type 5C adolescent idiopathic scoliosis (AIS) who underwent selective anterior spinal fusion (ASF). This study evaluated the incidence and predictors of shoulder imbalance after selective ASF for Lenke type 5C AIS. Methods: In total, 62 patients with Lenke type 5C AIS (4 men and 58 women, mean age at surgery of 15.5 ± 1.5 years) were included and divided into the following two groups according to the radiographic shoulder height (RSH) at the final follow-up: PSI and non-PSI groups. All patients in this study underwent a whole-spine radiological evaluation. Various spinal coronal and sagittal profiles on radiographs were compared between the 2 groups. The clinical outcomes were assessed using the Scoliosis Research Society (SRS)-22 questionnaires. Results: The mean final follow-up duration was 8.6 ± 2.7 years. PSI was observed in 10 patients (16.1%) immediately after surgery; however, in the long-term follow-up period, PSI improved in 3 patients spontaneously, whereas the remaining 7 patients had residual PSI. The preoperative RSH and correction rates of the major curve immediately after surgery or at the final follow-up were significantly larger in the PSI group than in the non-PSI group (p=.001, p=.023, and p=.019, respectively). Receiver operating characteristic curve analysis indicated that the cutoff values for preoperative RSH and the correction rates immediately after surgery and at the final follow-up were 11.79 mm (p=.002; area under the curve [AUC], 0.948), 71.0% (p=.026; AUC, 0.822), and 65.4% (p=.021; AUC, 0.835), respectively. No statistically significant difference was observed in the preoperative and final follow-up SRS-22 scores in any domain between the PSI and non-PSI groups. Conclusions: Paying attention to the preoperative RSH and avoiding excessive correction of the major curve can prevent the occurrence of shoulder imbalance after selective ASF for Lenke type 5C AIS.

Long-Term Clinical, Radiographic, and Cost Analysis of Corrective Spine Surgery for Adult Symptomatic Lumbar Deformity With a Mean of 7.5 years Follow-Up.

STUDY DESIGN: Multicenter retrospective study. OBJECTIVE: This study reports long-term clinical and radiographic outcomes in surgically treated patients with adult symptomatic lumbar deformity (ASLD). SUMMARY OF BACKGROUND DATA: The short-term results of corrective spinal surgery for ASLD are often favorable despite a relatively high complication profile. However, long-term outcomes have not been completely characterized. METHODS: A total of 169 surgically treated consecutive ASLD patients (≥50 yr) who achieved minimum 5 year follow-up were included (average 7.5 yr observation window, average age 67±8 yr, 96% female). The subjects were stratified by current age (50s, 60s, and 70s) and compared. Kaplan-Meier analysis was used to estimate the cumulative incidence of unplanned reoperation stratified by age group. Initial and overall direct costs of surgery were also analyzed. RESULTS: The SRS-22 at final follow-up was similar among the three groups (50s, 60s, and 70s; 4.0±0.5 vs. 3.8±0.7 vs. 3.8±0.7, respectively). The overall major complication rate was 56%, and 12% experienced late complications. The cumulative reoperation rate was 23%, and 4% required late reoperation. Patients in their 70s had a significantly higher reoperation rate (33%) and overall complication rate (65%). However, the late complication rate was not significantly different between the three groups (9% vs. 12% vs. 13%). Sagittal alignment was improved at two years and maintained to the final follow-up, whereas reciprocal thoracic kyphosis developed in all age groups. The direct cost of initial surgery was $45K±9K and increased by 13% ($53K±13K) at final follow-up. CONCLUSIONS: Long-term surgical outcomes for ASLDs were favorable, with a relatively low rate of late-stage complications and reoperations, as well as reasonable direct costs. Despite the higher reoperation and complication rate, ASLD patients of more advanced age achieved similar improvement to those in the younger age groups.

Circumferential Bone Fusion in Adult Spinal Deformity via Combination of Oblique Lateral Interbody Fusion and Grade 2 Posterior Column Osteotomy.

STUDY DESIGN: Retrospective study. OBJECTIVES: The combination of oblique lateral interbody fusion (OLIF) with grade 2 posterior column osteotomy (PCO) is an effective treatment for adult spinal deformity. However, grade 2 PCO may lead to pseudoarthrosis because it involves complete removal of the bilateral posterior facet joints. The main study objective was to determine the achievement rate of anterior and posterolateral fusion resulting in circumferential fusion in patients who underwent combined OLIF and grade 2 PCO. METHODS: This retrospective study included consecutive patients who underwent OLIF and grade 2 PCO. The group comprised a long fusion group, with fusion from the thoracic level to the ilium, and a short fusion group, with fusion within the lumbar region. The OLIF with percutaneous pedicle screw insertion group was also used for reference. The Brantigan-Steffee-Fraser classification was used to assess interbody fusion and Lenke classification for assessment of posterolateral fusion. RESULTS: Sixty-six patients with 109 lumbar levels were included in the study. We observed 100% anterior fusion in all 3 groups. The fusion rate for posterolateral fusion between the OLIF-grade 2 PCO group was 97%, with very low (3%) non-circumferential fusion (pseudoarthrosis only at the osteotomy site). In most cases, solid posterolateral fusions (Lenke A) occurred within 24 months. CONCLUSIONS: The combination of OLIF and grade 2 PCO resulted in circumferential fusion for most (97%) of the cases within 24 months. OLIF and grade 2 PCO are considered a good combination treatment to achieve sufficient lumbar lordosis and solid bone fusion.

Assessment of the Necessity of Osteoporosis Treatment for Patients with Low Bone Density in Diffuse Idiopathic Skeletal Hyperostosis.

Introduction: Although patients with diffuse idiopathic skeletal hyperostosis (DISH) do not have low bone density, it is a risk factor for spine fractures associated with DISH. We investigated the characteristics and bone metabolism markers of patients with DISH having low bone density to assess whether osteoporosis medication is necessary to prevent fractures. Methods: A cross-sectional study was conducted between April 1, 2008, and March 31, 2019. The 86 patients included were divided into two groups according to their T-scores-one group had low bone density and DISH, and the other group did not. Group A (T-score≤-1) and B (T-score>-1) data were adjusted for confounding factors and compared for differences in age, body weight, maximum number of vertebral bodies with bony bridges between adjacent vertebrae (max VB), and previous history (hypertension, malignant tumors, diabetes mellitus, cardiac diseases, chronic renal failure, and spinal fractures). In Group A, multiple linear regression was used to investigate relationships among max VB, femur bone mineral density (BMD), total type I procollagen N-terminal propeptide (P1NP), and tartrate-resistant acid phosphatase 5b (TRACP-5b). Results: Group A had 36, and Group B had 50 male patients with DISH. Patients in Group B were heavier than those in Group A. The mean femur BMD in Group A was age-appropriate, and that in Group B was higher than the age-appropriate femur BMD. The mean values of P1NP and TRACP-5b were within the normal range. Max VB was positively correlated with total P1NP in Group A. Total P1NP was significantly and positively correlated with TRACP-5b. Conclusions: The DISH group with a T-score of ≤-1 was age-appropriate. The group with a T-score of >-1 had higher BMD because of their higher body weight. The group with a T-score of ≤-1 had good bone metabolism and did not require aggressive osteoporosis treatment.

Reduction Capacity and Factors Affecting Slip Reduction Using Cortical Bone Trajectory Technique in Transforaminal Lumbar Interbody Fusion for Degenerative Spondylolisthesis.

Introduction: Vertebral slip reduction has been recommended in arthrodesis for lumbar degenerative spondylolisthesis (LDS) to achieve balanced spinal alignment and bone fusion. However, what determines the degree of slip reduction using cortical bone trajectory technique for lumbar pedicle screw insertion is yet to be determined. Thus, in this study, we aim to investigate the slip reduction capacity using cortical bone trajectory (CBT) technique and to identify factors affecting the slip reduction rate. Methods: This is a retrospective radiological evaluation of prospectively collected patients. In total, 49 consecutive patients who underwent single-level transforaminal lumbar interbody fusion for LDS using the CBT technique were included (mean follow-up: 28.9 months). Firstly, radiological parameters of fused segment including the percentage of anterior vertebral slip (%slip), lordotic angle, and disk height were measured. Then, patient and procedure-related parameters were examined to determine factors related to the slip reduction rate using multiple regression analysis. Results: The %slip was reduced from 15.0±4.8 to 1.6±2.3% immediately after surgery and 2.2±2.9% at the last follow-up (p<0.01), with a slip reduction rate of 87.5±15.7% and correction loss of 0.6±2.1%. As per multivariate regression analysis, it was found that preoperative %slip (standardized regression coefficient [ß]=-0.55, p=0.003) and the depth of screw insertion in the caudal vertebra (ß=0.38, p=0.03) were significant independent factors affecting slip reduction rate (adjusted R2=0.29, p=0.008). Conclusions: To the best of our knowledge, this study is the first to investigate the capacity for and factors affecting slip reduction using the CBT technique for LDS. The CBT technique may be a useful option for achieving slip reduction, and the depth of screw insertion in the caudal vertebra was identified as a significant technical factor to obtain a more significant reduction of slipped vertebra.

Normal pressure hydrocephalus due to an iatrogenic giant lumbar pseudomeningocele after posterior lumbar interbody fusion: illustrative case.

BACKGROUND: Iatrogenic pseudomeningocele incidence after lumbar surgery is 0.068%-2%, and most lumbar pseudomeningoceles are smaller than 5 cm; however, in rare cases, "giant" pseudomeningoceles greater than 8 cm in size may develop. Normal pressure hydrocephalus (NPH) is another rare condition in which the ventricles expand despite the presence of normal intracranial pressure. To date, pseudomeningocele associated with NPH has not been reported. OBSERVATIONS: An 80-year-old woman underwent L3-5 laminectomy and posterior lumbar interbody fusion, and her symptoms improved after surgery. However, dementia appeared 1 month after surgery. Repeated brain computed tomography showed ventricular enlargement, and lumbar magnetic resonance imaging showed a long pseudomeningocele in the subcutaneous tissues at the L4 level. Here, the authors report a rare case of an iatrogenic giant pseudomeningocele accompanied by NPH after lumbar surgery. The symptoms of NPH in the present case occurred after spinal surgery and recovered after dural repair surgery, indicating that the changes in cerebrospinal fluid circulation and/or pressure due to pseudomeningoceles may cause NPH. LESSONS: The prevention of dural tears through precise surgical technique and primary repair of dural tears are the best approaches to prevent pseudomeningocele incidence and subsequent events.

Safety and immunogenicity of the Pfizer/BioNTech SARS-CoV-2 mRNA third booster vaccine dose against the BA.1 and BA.2 Omicron variants.

BACKGROUND: The Omicron variant of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) was identified in Japan in November 2021. This variant contains up to 36 mutations in the spike protein, the target of neutralizing antibodies, and can escape vaccine-induced immunity. A booster vaccination campaign began with healthcare workers and high-risk groups. The safety and immunogenicity of the three-dose vaccination against Omicron remain unknown. METHODS: A total of 272 healthcare workers were initially evaluated for long-term vaccine safety and immunogenicity. We further established a vaccinee panel to evaluate the safety and immunogenicity against variants of concern (VOCs), including the Omicron variants, using a live virus microneutralization assay. FINDINGS: Two-dose vaccination induced robust anti-spike antibodies and neutralization titers (NTs) against the ancestral strain WK-521, whereas NTs against VOCs were significantly lower. Within 93-247 days of the second vaccine dose, NTs against Omicron were completely abolished in up to 80% of individuals in the vaccinee panel. Booster dose induced a robust increase in anti-spike antibodies and NTs against the WK-521, Delta, and Omicron variants. There were no significant differences in the neutralization ability of sera from boosted individuals among the Omicron subvariants BA.1, BA.1.1, and BA.2. Boosting increased the breadth of humoral immunity and cross-reactivity with Omicron without changes in cytokine signatures and adverse event rate. CONCLUSIONS: The third vaccination dose is safe and increases neutralization against Omicron variants. FUNDING: This study was supported by grants from AMED (grants JP21fk0108104 and JP21mk0102146).

Influence of Pedicle Screw Insertion Depth on Posterior Lumbar Interbody Fusion: Radiological Significance of Deeper Screw Placement.

STUDY DESIGN: Retrospective case series. OBJECTIVES: To investigate the influence of screw size on achieving bone fusion in posterior lumbar interbody fusion (PLIF). METHODS: In total, 137 consecutive patients with L4 degenerative spondylolisthesis who underwent single-level PLIF at L4-L5 were evaluated. Factors investigated for their contribution to bone fusion included: 1) age, 2) sex, 3) body mass index, 4) bone mineral density, 5) intervertebral mobility, 6) screw diameter, 7) screw length, 8) screw fitness in the pedicle (%fill), 9) screw depth in the vertebra (%depth), 10) screw angle, 11) facetectomy, 12) crosslink connector, and 13) cage material. RESULTS: Bone fusion was confirmed in 88.2% of patients. The comparison between fusion (+) and fusion (-) groups showed no significant differences in screw size. The %fill and %length were significantly greater in the fusion (+) group than in the fusion (-) group (%fill: 58.5% ± 7.5% vs 52.3% ± 7.3%, respectively, P = .005; %depth: 59.8% ± 9.7% vs 50.3% ± 13.8%, respectively, P = .025). Multivariate logistic regression analysis revealed that %fill (odds ratio [OR]= 1.11, P = .025) and %depth (OR = 1.09, P = .003) were significant independent factors affecting bone fusion. Receiver operating characteristic curve analyses identified a %fill of 60.0% and a %depth of 54.2% as optimal cutoff values for achieving bone fusion. CONCLUSIONS: Screw size should be determined based on the screw fitness in the pedicle (%fill > 60%) and screw insertion depth in the vertebral body (%depth > 54.2%) according to individual vertebral anatomy in L4-L5 PLIF.

Radiological comparison of penetrating endplate trajectory versus anterior bicortical trajectory for sacral pedicle screw insertion in posterior lumbosacral interbody fusion.

BACKGROUND: The bicortical or tricortical fixation technique with purchase into the anterior sacral wall or promontory has been recommended to achieve rigid sacral pedicle screw fixation, which carries the potential risk of neurovascular injuries. The penetrating endplate screw (PES) technique was proposed as an alternative screw trajectory to facilitate both strong fixation and safety. However, there has been no report on the practical significance of using the PES technique. The aim of the present study was to investigate radiological outcomes using the PES technique for lumbosacral fusion by comparing it with the anterior bicortical technique. METHODS: The subjects consisted of 44 patients with L5 isthmic spondylolisthesis who underwent single-level posterior lumbar interbody fusion at L5-S using the PES technique (20 patients) or the anterior bicortical technique (24 patients) and were followed up for > 2 years (mean follow-up: 36.6 months). Screw loosening and bone fusion were radiologically assessed and compared between the two groups. Factors contributing to bone fusion were investigated using the following factors: (1) age, (2) sex, (3) body mass index, (4) bone mineral density, (5) screw diameter, (6) screw length, (7) pelvic incidence, (8) crosslink connector, (9) cage material, and (10) sacral screw insertion technique. RESULTS: Respective screw loosening and bone fusion rates were 10.0 and 90.0% using the PES technique and 29.2 and 79.2% using the anterior bicortical technique, with no significant differences between the two techniques. Multivariate logistic regression analysis revealed that the age (odds ratio = 0.87, p = 0.02) and PES technique (odds ratio = 22.39, p = 0.02) were significant independent factors contributing to bone fusion. CONCLUSIONS: This is the first study to demonstrate the significance of using the PES technique to improve radiological outcomes. The PES technique could be a valid option for lumbosacral fixation for L5 isthmic spondylolisthesis in terms of improved bone fusion.

Selective Anterior Fusion Surgery Does Not Influence Global Spinal Sagittal Alignment in Lenke Type 5 Adolescent Idiopathic Scoliosis Patients.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: The aim of this study was to evaluate the changes in global spinal sagittal alignment (GSSA) following selective anterior spinal fusion (ASF) in patients with Lenke type 5 adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Few studies have assessed the changes in postoperative GSSA, including cervical, thoracic, and lumbosacral sagittal alignment in AIS patients with major thoracolumbar/lumbar (TL/L) curve who underwent selective ASF. METHODS: Fifty-two patients with Lenke type 5 AIS (two males and 50 females, mean age at surgery of 16.4 ±â€Š3.1 years) were included in this study. The average final follow-up was 8.3 ±â€Š3.1 years after surgery. The variations of outcome variables were analyzed in various spinal sagittal profiles using radiographic outcomes (pre-operation, immediate post-operation, and final follow-up). The clinical outcomes at the final follow-up were assessed using Scoliosis Research Society (SRS)-22 and Oswestry Disability Index (ODI) questionnaires. RESULTS: The mean Cobb angle of the main TL/L and minor thoracic curve was significantly improved after selective ASF, which was maintained up to the final follow-up. However, in all cases, the various sagittal parameters examined (sagittal vertical axis [SVA], C2-7 SVA, C2-7 lordosis, T1 slope, thoracic kyphosis, T10-L2 kyphosis, lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope), did not significantly change in the immediate postoperative period, and all GSSA parameters were maintained up to the final follow-up. Furthermore, the magnitude of coronal curve correction and fused levels did not affect each GSSA parameter postoperatively. During the period up to the final follow-up, no significant clinical symptoms were observed. The final SRS-22 global score was 4.5 ±â€Š0.3, and ODI scored 0.8 ±â€Š2.4. CONCLUSION: Selective ASF did not influence various GSSA parameters postoperatively and could maintain excellent correction for coronal deformity with satisfactory final functional and clinical outcomes confirmed by long-term follow-up.Level of Evidence: 4.

Association of Continuous Vertebral Bone Bridges and Bone Mineral Density with the Fracture Risk in Patients with Diffuse Idiopathic Skeletal Hyperostosis.

STUDY DESIGN: Cross-sectional study. PURPOSE: To examine whether the number of continuous vertebral bone bridges and bone mineral density (BMD) influence the fracture risk in diffuse idiopathic skeletal hyperostosis (DISH) patients. OVERVIEW OF LITERATURE: Bone bridges connecting through the intervertebral body in DISH create long lever arms that can increase the risk of fractures from minor trauma. DISH patients have a BMD that is higher than or comparable to those of age-matched healthy subjects. METHODS: We examined the computed tomography scans from the thoracic vertebra to the sacrum used to diagnose DISH in 140 patients (98 men and 42 women; average age, 78.6 years). We compared patients who did (n=52) and did not have (n=88) fractures at the continuous vertebral bodies fused by bone bridges. The relationship between the vertebral fractures and the maximum number of vertebrae that are bony cross-linked with contiguous adjacent vertebrae (max VB) from the thoracic vertebra to the sacrum or from the lumbar vertebra to the sacrum and proximal femur BMD were analyzed using a logistic regression model. RESULTS: We found that after adjusting for the confounding factors, higher max VB, both from the thoracic vertebrae to the sacrum and the lumbar vertebrae to the sacrum, was associated with a higher risk of vertebral fractures. This difference was statistically significant. The risk was higher when only the lumbar vertebrae to the sacrum was considered (thoracic vertebrae to the sacrum: odds ratio, 1.21; p<0.05; lumbar vertebrae to the sacrum: odds ratio, 2.78; p<0.01). Moreover, low proximal femur BMD in DISH patients raises the fracture risk (odds ratio, 0.47; p<0.01). CONCLUSIONS: Many continuous vertebral bone bridges, especially those that extend to the lumbar spine and low proximal femur BMD, are risk factors for fracture in DISH patients.

Maximum number of bone cross-linked vertebrae: an index for BMD in diffuse idiopathic skeletal hyperostosis.

INTRODUCTION: The maximum number of vertebral bodies with bony bridges between adjacent vertebrae (max VB) helps assess the risk of fracture in diffuse idiopathic skeletal hyperostosis (DISH). In addition to max VB, the maximum thickness of bone cross-bridges (max TB) may be an index of bone mineral density (BMD). Therefore, this study investigated the relationship among max VB, max TB, and BMD. MATERIALS AND METHODS: The participants in this cross-sectional study were male patients (n = 123) with various max VB from the thoracic vertebrae to the sacrum without sacroiliac ankylosis. The participants were grouped by max VB. For example, a group with max VB from 4 to 8 would be listed as max VB (4-8). The relation between femur proximal BMD and mean max TB and max VB was assessed. Femur proximal BMD was then compared after adjusting for confounding factors. RESULTS: The results indicated that max VB was correlated with femur proximal BMD in max VB (0-8) and max VB (9-18) groups. The mean max TB was correlated only with femur proximal BMD in max VB (0-8). After adjusting, max VB (4-8) showed a significantly higher femur proximal BMD than max VB (0-3) and max VB (9-18). CONCLUSION: Femur proximal BMD and mean max TB showed different trends after max VB = 9, which suggests that max VB is an index of BMD, and that DISH has at least two possible populations in terms of BMD and bone cross-link thickness.

Tuberculous spondylitis following intravesical Bacillus Calmette-Guérin therapy for bladder cancer surgically treated through the anterior approach.

Intravesical BCG therapy is commonly used to treat superficial bladder cancer. Although various complications associated with this therapy have been reported, tuberculous spondylitis is uncommon. Here, we report a rare case of tuberculous spondylitis that occurred after intravesical BCG therapy for bladder cancer. A man in his 80s received BCG immunotherapy for bladder cancer and developed low back pain after treatment. Remarkably, he presented with neurological symptoms. Spondylitis was suspected on imaging. CT-guided biopsy was performed to confirm the diagnosis. Consequently, Mycobacterium bovis was identified as the causative pathogen by multiplex PCR. Multidrug therapy, administered for several months, was ineffective. Therefore, surgery was performed through an anterior approach. The symptoms, including low back pain, improved and postoperative C reactive protein tests were within the normal range. Tuberculous spondylitis following BCG therapy should be considered in cases with a history of bladder cancer treatment.

Depth of vertebral screw insertion using a cortical bone trajectory technique in lumbar spinal fusion: radiological significance of a long cortical bone trajectory.

OBJECTIVE: Contrary to original cortical bone trajectory (CBT), "long CBT" directed more anteriorly in the vertebral body has recently been recommended because of improved screw fixation and load sharing within the vertebra. However, to the authors' knowledge there has been no report on the clinical significance of the screw length and screw insertion depth used with the long CBT technique. The aim of the present study was to investigate the influence of the screw insertion depth in the vertebra on lumbar spinal fusion using the CBT technique. METHODS: A total of 101 consecutive patients with L4 degenerative spondylolisthesis who underwent single-level posterior lumbar interbody fusion at L4-5 using the CBT technique were included (mean follow-up 32.9 months). Screw loosening and bone fusion were radiologically assessed to clarify the factors contributing to these outcomes. Investigated factors were as follows: 1) age, 2) sex, 3) body mass index, 4) bone mineral density, 5) intervertebral mobility, 6) screw diameter, 7) screw length, 8) depth of the screw in the vertebral body (%depth), 9) facetectomy, 10) crosslink connector, and 11) cage material. RESULTS: The incidence of screw loosening was 3.1% and bone fusion was achieved in 91.7% of patients. There was no significant factor affecting screw loosening. The %depth in the group with bone fusion [fusion (+)] was significantly higher than that in the group without bone fusion [fusion (-)] (50.3% ± 8.2% vs 37.0% ± 9.5%, respectively; p = 0.001), and multivariate logistic regression analysis revealed that %depth was a significant independent predictor of bone fusion. Receiver operating characteristic curve analysis identified %depth > 39.2% as a predictor of bone fusion (sensitivity 90.9%, specificity 75.0%). CONCLUSIONS: This study is, to the authors' knowledge, the first to investigate the significance of the screw insertion depth using the CBT technique. The cutoff value of the screw insertion depth in the vertebral body for achieving bone fusion was 39.2%.

Clinical Efficacies of the Minimal Retroperitoneal Approach for Infectious Spondylodiscitis: A Clinical Case Series.

INTRODUCTION: An anterior surgical approach for severe infectious spondylodiscitis in the lumbar region is optimal but not always atraumatic. The aim of this study was to evaluate the efficacy and safety of a minimal anterior-lateral retroperitoneal approach, also known as a surgical approach for oblique lumbar interbody fusion, for cases with severe infectious spondylodiscitis with osseous defects. METHODS: Twenty-four consecutive patients who underwent anterior debridement and spinal fusion with an autologous strut bone graft for infectious spondylodiscitis with osseous defects were reviewed retrospectively. Eleven patients underwent the minimal retroperitoneal approach (Group M), and 13 underwent the conventional open approach (Group C). Peri- and postoperative clinical outcomes, that is, estimated blood loss (EBL), operative time (OT), creatine kinase (CK) level, visual analog scale (VAS), and rates of bone union and additional posterior instrumentation, were evaluated, and the differences between both groups were assessed statistically. RESULTS: Mean EBL, serum CK on the 1st postoperative day, and VAS on the 14th postoperative day were 202.1 mL, 390.9 IU/L, and 9.5 mm in Group M and 648.3 mL, 925.5 IU/L, and 22.3 mm in Group C, respectively, with statistically significant differences between the groups. There were no statistically significant intergroup differences in OT and rates of bone union and additional posterior instrumentation. CONCLUSIONS: Anterior debridement and spinal fusion using the minimal retroperitoneal approach is a useful and safe surgical technique. Although a preponderance of the minimal approach regarding early bone union is not validated, this technique has the advantages of conventional open surgery, but reduces blood loss, muscle injury, and pain postoperatively.