The positive impact of smoking cessation on fracture risk in a nationwide cohort study.

Many studies sought to demonstrate the association between smoking and fracture risk. However, the correlation between smoking and fractures remains controversial. This study aimed to examine the impact of smoking and smoking cessation on the occurrence of fractures using prospective nationwide cohort data. We enrolled those who underwent a National Health Insurance Service (NHIS) health checkup in 2009-2010 who had a previous health checkup 4-year prior (2005-2006). The study population of 4,028,559 subjects was classified into three groups (non-smoker, smoking cessation, current smoker). The study population was also analyzed according to fracture type (all fractures, vertebral fracture, hip fracture). Lastly, the smoking cessation group and current smoker group were divided into four subgroups based on a lifetime smoking amount cut-off of 20 pack-years (PY). Multivariate-adjusted hazard ratios (HRs) of fracture were examined through a Cox proportional hazards model. After multivariable adjustment, non-smokers showed the lowest risk of fracture (HR = 0.818, CI 0.807-0.828, p < 0.0001) and smoking cessation significantly lowered the risk of fracture (HR 0.938, 95% CI 0.917-0.959, p < 0.0001) compared to current smokers. Regardless of 20PY, all smoking cessation subgroups showed significantly less risk of fractures than current smokers with ≥ 20PYs. Smoking increases the risk of fracture, and smoking cessation lowers the risk of fracture.

Surgical Outcomes of Extensive Dome-Like Laminoplasty Using En Bloc Resection of C2 Inner Lamina for Patients With Severe Cord Compression Behind C2 Body.

STUDY DESIGN: A retrospective, single-center study. OBJECTIVE: The aim of this study is to evaluate the efficacy and safety of a newly developed extensive dome-like laminoplasty using en bloc resection of the C2 inner lamina in patients with severe cord compression behind the C2 body. SUMMARY OF BACKGROUND DATA: A surgery for severe cord compression behind C2 body is challenging for spinal surgeons. To date, there has been no established solution for severe cord compression behind the C2 body. MATERIALS AND METHODS: Patients with severe cord compression behind the C2 body who underwent posterior surgery consecutively were enrolled. Extensive dome-like laminoplasty that was newly developed was performed to remove en bloc removal of the C2 inner lamina were performed. Preoperative and postoperative canal diameters behind the C2 and mean removed area of the C2 inner lamina were measured using MRI and CT scan. Clinical and radiographic parameters were assessed preoperative and postoperative periods. In addition, perioperative complications were analyzed. RESULTS: A total of 36 patients underwent extensive dome-like laminoplasty and their diagnoses were ossification of the posterior longitudinal ligament (OPLL, 66.7%) and congenital stenosis with spondylosis (33.3%). The mean canal diameter behind the C2 increased from 9.85 (2.28) mm preoperatively to 19.91 (3.93) mm at the last follow-up ( P <0.001). Clinically, neck and arm visual analog scale, Japanese Orthopaedic Association score, and neck disability index significantly improved at postoperative 1 month ( P <0.05), and the scores were maintained until the last follow-up. No meaningful radiographic changes occurred after the surgeries. During the procedures, there were no particular complications, but one patient showed deteriorated myelopathic symptoms and underwent additional C1-C2 decompressive surgery. CONCLUSIONS: After extensive dome-like laminoplasty, surgical outcomes are satisfactory, and complications are rare. This technique may be a viable option for patients with severe cord compression behind the C2 body. LEVEL OF EVIDENCE: Level IV.

Ideal length of accessory rod for the prevention of rod fracture after pedicle subtraction osteotomy in adult spinal deformity: short or long?

OBJECTIVE: Pedicle subtraction osteotomy (PSO) is an effective surgical procedure for adult spinal deformity (ASD). However, the complexity of the procedure and its associated complications including rod fracture (RF) remain challenging issues. Among several RF reduction methods, the accessory rod (AR) is an important surgical technique. To date, knowledge about the ideal length and configuration of the AR is limited. This study aimed to assess the influence of the connection levels and configuration of the AR on RF occurrence in patients with ASD who underwent long level constructs and PSO. METHODS: The authors retrospectively selected 57 consecutive patients (mean age 70.6 years) who underwent deformity correction including PSO and the AR technique with a minimum 2-year follow-up. The patients were classified into a non-RF group (n = 49) and an RF group (n = 8). Along with analysis of patient and radiological factors in the 2 groups, comparative studies were performed including configuration of the AR (D shaped vs linear shaped) and the connection levels of AR (long AR [the lower end below S1-2] vs short AR [above L5-S1]). RESULTS: The overall rate of RF incidence was 14% (8/57 cases) at an average of 42.5 months (2 patients with unilateral RF and 6 with bilateral RF). RF occurred most commonly at the L4-5 level, below the lower end of the AR: 6 below the lower end of the AR and 2 at the PSO site. There were no significant differences in patient and radiological factors between the groups. Comparisons between the 2 groups indicated that more RFs occurred when the configuration of the AR was a linear shape (p = 0.016) and when the distal end of the AR was above L5-S1 (p = 0.025). CONCLUSIONS: In this study the authors found that the D-shaped configuration of the AR and lower end of the AR below S1-2 (i.e., long AR) could be preventive methods for reducing RF after deformity correction performed using PSO and the AR technique for ASD. Here, the authors have provided the first comprehensive outline for the AR technique. These findings could establish effective guidelines for spine surgeons.

Effects of Minimally Invasive Lateral Lumbar Interbody Fusion with Accessory Rod Technique on Rod Fracture in Adult Spinal Deformity Surgery: Analysis of 239 Patients.

STUDY DESIGN: A retrospective study. OBJECTIVES: To analyze factors associated with rod fracture (RF) in adult spinal deformity (ASD), and to assess whether the accessory rod (AR) technique can reduce RF occurrence in deformity correction in the setting of minimally invasive lateral lumbar interbody fusion (LLIF). SUMMARY OF BACKGROUND DATA: Instrumentation failure is the most common reason for revision surgery in ASD. Several RF reduction methods have been introduced. However, there are insufficient studies on postoperative RF after deformity correction using minimally invasive LLIF. METHODS: This study included 239 patients (average age 71.4 y and a minimum 2-year follow up) with ASD who underwent long-segment fusion from T10 to sacrum with sacropelvic fixation. Patients were classified into the non-RF group and the RF group. After logistic regression analysis of the risk factors for RF, subgroup analyses were performed; pedicle subtraction osteotomy (PSO) with 2-rod (P2 group) versus PSO with 2-rod and AR (P4 group), and LLIF with 2-rod (L2 group) versus LLIF with 2-rod and AR (L4 group). RESULTS: RF occurred in 50 patients (21%) at an average of 25 months. RF occurred more frequently in patients who underwent PSO than in those who underwent LLIF (P=0.002), and the use of the AR technique was significantly higher in the non-RF group (P<0.05).Following logistic regression analysis, preoperative PI-LL mismatch, PSO, and the AR technique were associated with RF. In subgroup analyses, RF incidence was 65% (24/37 cases) of P2 group, 8% (4/51 cases) of P4 group, and 21% (22/105 cases) of L2 group. In the L4 group, there was no RF. CONCLUSION: Minimally invasive multilevel LLIF with the AR technique is capable of as much LL correction as conventional PSO and appears to be an effective method for reducing RF.

Does the Amount of Correction of Sagittal Deformity Really Promote Proximal Junctional Kyphosis? Multivariate Analyses According to Uppermost Instrumented Vertebra Levels.

BACKGROUND: The present study assumed that the effects of deformity correction amounts on proximal junctional kyphosis (PJK) development after long deformity surgery would vary according to uppermost instrumented vertebrae (UIV) levels. Our study was to reveal the association between the amount of correction and PJK according to UIV levels. METHODS: Adult spinal deformity patients aged >50 years who underwent thoracolumbar fusion (≥4 levels) were included. PJK was defined by proximal junctional angles ≥15°. Presumed demographic and radiographic risk factors for PJK were evaluated including parameters regarding the correction amount such as postoperative change in lumbar lordosis and postoperative offset grouping, the value associated with age-adjusted pelvic incidence-lumbar lordosis mismatch. The patients were divided according to UIV levels of T10 or above (group A) and T11 or below (group B). Multivariate analyses were performed separately for both groups. RESULTS: The present study included 241 patients (74 for group A and 167 for group B). PJK developed in approximately half of all patients within an average of 5 years of follow-up. For group A, only body mass index (P = 0.002) was associated with PJK. No radiographic parameters were correlated. For group B, postoperative change in lumbar lordosis (P = 0.009) and offset value (P = 0.030) were significant risk factors for PJK development. CONCLUSIONS: The correction amount of sagittal deformity increased the risk of PJK only in patients with UIV at or below T11. However, it was not associated with PJK development in patients with UIV at or above T10.

Difference between Anterior and Posterior Cord Compression and Its Clinical Implication in Patients with Degenerative Cervical Myelopathy.

In degenerative cervical myelopathy (DCM), the low anteroposterior compression ratio of the spinal cord is known to be associated with a neurologic deficit. However, there is little detailed analysis of spinal cord compression. Axial magnetic resonance images of 183 DCM patients at normal C2-C3 and maximal cord compression segments were analyzed. The anterior (A), posterior (P), and anteroposterior length and width (W) of the spinal cord were measured. Correlation analyses between radiographic parameters and each section of Japanese Orthopedic Association (JOA) scores and comparisons of the patients divided by A (below or above 0, 1, or 2 mm) were performed. Between C2-C3 and maximal compression segments, the mean differences of A and P were 2.0 (1.2) and 0.2 (0.8) mm. The mean anteroposterior compression ratios were 0.58 (0.13) at C2-C3 and 0.32 (0.17) at maximal compression. The A and A/W ratio were significantly correlated with four sections and the total JOA scores (p < 0.05), but the P and P/W ratio did not demonstrate any correlations. Patients with A < 1 mm had significantly lower JOA scores than those with A ≥ 1 mm. In patients with DCM, spinal cord compression occurs mainly in the anterior part and the anterior cord length of <1 mm is particularly associated with neurologic deficits.

Significance of paraspinal muscle quality in risk between single and multiple osteoporotic vertebral fractures.

PURPOSE: To compare paraspinal muscle quality between patients with single and multiple osteoporotic vertebral fractures (OVFs) and evaluate the role of the paraspinal muscles in OVFs. METHODS: A total of 262 consecutive patients with OVFs were retrospectively analyzed in two groups: those with single OVF (n = 173) and those with multiple OVFs (n = 89). The cross-sectional area (CSA) and fatty degeneration of the paraspinal muscles were calculated from axial T2-weighted magnetic resonance imaging at the level of the L4 upper endplate by manual tracing in ImageJ software. Pearson's correlation analysis was performed to analyze correlations of paraspinal muscle quality to multiple OVFs. RESULTS: FD in all the paraspinal muscles was significantly higher in the multiple OVF group than the single OVF group (all p < 0.005). The functional CSA (fCSA) of the paraspinal muscles was significantly lower in the multiple OVF group than the single OVF group (all Ps < 0.001), except for the erector spine (p = 0.304). The Pearson's correlation analysis showed significant positive inter-correlations for the fCSAs of all the paraspinal muscles and the occurrence of multiple OVFs. CONCLUSIONS: The pure muscle volumes of the multifidus, psoas major, and quadratus lumborum were lower in patients with multiple OVFs than in those with a single OVF. Furthermore, the inter-correlation among all the paraspinal muscles indicate that the muscle-bone crosstalk profoundly existed in vertebral fracture cascade. Therefore, special attention to paraspinal muscle quality is needed to prevent progression to multiple OVFs.

Impact of lamina-open side on unilateral open door laminoplasty in patients with degenerative cervical myelopathy.

Surgeons should select one side for cervical unilateral open door laminoplasty (UODL). However, few reports suggest proper guidelines for deciding which side to open. The aim of this study is to evaluate the impact of opening side in UODL on dominant cord compressive or symptomatic side. 193 degenerative cervical myeloradiculopathy patients with followed-up more than 2 years were enrolled. In all cases, UODL was performed uniformly on the right side. Patients were sub-grouped based on preoperative dominant 3 characteristics: cord compression, myelopathy symptom and radiculopathy symptom (right, symmetric, left). Pre- and postoperative radiographic and clinical parameters and incidence of postoperative C5 palsy were analyzed and compared among the groups. According to dominant compressive side, there were no significant differences in postoperative radiographic and clinical parameters among three groups. According to dominant myelopathy or radiculopathy symptom side, there were no significant differences of all radiographic and clinical parameters postoperatively, except slightly lower neck VAS in groups of preoperative right dominant myelopathy or radiculopathy symptom side at postoperative 1 month. C5 palsies occurred in twelve patients (6.2%), but the incidences were not different among the groups. Therefore, when performing UODL, the choice of lamina opening side can be left to surgeon's preference.

Clostridium difficile infection after orthopedic surgery: Incidence, associated factors, and impact on outcome.

BACKGROUND: To identify the incidence, associated factors, and impact of hospital-acquired Clostridium difficile infection (CDI) among patients who have undergone orthopedic surgery. METHODS: We retrospectively reviewed the charts of all adults patients who underwent orthopedic surgery from January 2016 through December 2017 at a tertiary hospital. RESULTS: Of 7,363 patients who underwent orthopedic surgical procedures, 52 (0.7%) developed hospital-acquired CDI. The independent factors associated with CDI were age ≥65 years (adjusted odds ratio [aOR], 3.4; P < .001), preoperative hospital stay ≥3 days (aOR, 3.7; P < .001), operating time ≥3 hours (aOR, 2.5; P < .005), and antibiotic use for infection treatment (aOR, 4.3; P < .001). After adjusting for the timing of CDI using a multistate model, the mean excess LOS attributable to CDI was 2.8 days (95% confidence interval [CI], 0.4-5.3). The impact of CDI on excess LOS was more evident among patients aged ≥65 years (4.4 days; 95% CI, 1.8-7.0) and those with any comorbidity (5.6 days; 95% CI, 3.0-8.1). CONCLUSIONS: The overall incidence of CDI after orthopedic surgery was 0.7%. The occurrence of CDI after orthopedic surgery contributes to increased LOS. The greatest impact of CDI on LOS occurs among elderly patients and patients with comorbidities.

Cervical Radiculopathy: Focus on Factors for Better Surgical Outcomes and Operative Techniques.

For patients with cervical radiculopathy, most studies have recommended conservative treatment as the first-line treatment; however, when conventional treatment fails, surgery is considered. A better understanding of the prognosis of cervical radiculopathy is essential to provide accurate information to the patients. If the patients complain of persistent and recurrent arm pain/numbness not respond to conservative treatment, or exhibit neurologic deficits, surgery is performed using anterior or posterior approaches. Anterior cervical discectomy and fusion (ACDF) has historically been widely used and has proven to be safe and effective. To improve surgical outcomes of ACDF surgery, many studies have been conducted on types of spacers, size/height/position of cages, anterior plating, patients' factors, surgical techniques, and so forth. Cervical disc replacement (CDR) is designed to reduce the incidence of adjacent segment disease during long-term follow-up by maintaining cervical spine motion postoperatively. Many studies on excellent indications for the CDR, proper type/size/shape/height of the implants, and surgical techniques were performed. Posterior cervical foraminotomy is a safe and effective surgical option to avoid complications associated with anterior approach and fusion surgery. Most recent literature demonstrated that all three surgical techniques for patients with cervical radiculopathy have clear advantages and disadvantages and reveal satisfactory surgical outcomes under a proper selection of patients and application of appropriate surgical methods. For this, it is important to fully understand the factors for better surgical outcomes and to adequately practice the operative techniques for patients with cervical radiculopathy.

Extent and characteristic of relationships in canal dimension and canal body ratio between cervical and lumbar spine.

A known prevalence of concurrent cervical and lumbar spinal stenosis was shown to be 5-25%, but there is a lack of evidence regarding direct relationships in canal dimension and canal-body ratio between cervical and lumbar spine. Total 247 patients (mean age: 61 years, male: 135) with cervical and lumbar computed tomography scans were retrospectively reviewed. Midsagittal vertebral body and canal diameters in reconstructed images were measured at all cervical and lumbar vertebrae, and canal-body ratios were calculated. The canal diameter and ratio were also compared according to the gender and age, and correlation analysis was performed for each value. There were significant correlations between cervical (C3-C7) and lumbar (L1-L5) canal dimension (p < 0.001). C5 canal diameter was most significantly correlated with L4 canal diameter (r = 0.435, p < 0.001). Cervical canal-body ratios (C3-C7) were also correlated with those of lumbar spine (L1-L5) (p < 0.001). The canal-body ratio of C3 was most highly correlated with L3 (r = 0.477, p < 0.001). Meanwhile, mean canal-body ratios of C3 and L3 were significantly smaller in male patients than female (p = 0.038 and p < 0.001) and patient's age was inversely correlated with C5 canal diameter (r = - 0.223, p < 0.001) and C3 canal-body ratio (r = - 0.224, p < 0.001). Spinal canal dimension and canal-body ratio have moderate degrees of correlations between cervical and lumbar spine and the elderly male patients show the tendency of small canal diameter and canal-body ratio. This relationship of cervical and lumbar spine can be an important evidence to explain to the patients.

Diagnostic usefulness of 10-step tandem gait test for the patient with degenerative cervical myelopathy.

Tandem gait is considered one of the most useful screening tools for gait impairment. The aim of this study is to evaluate diagnostic usefulness of 10-step tandem gait test for the patients with degenerative cervical myelopathy (DCM). Sixty-two DCM patients were compared to 55 persons without gait abnormalities as control. We counted the number of consecutive steps and graded into five according the number of steps and stability. Five grades of tandem gait were investigated for association with clinical parameters including qualitative Japanese orthopedic association (JOA) sub-score for lower extremities and Nurick scale and quantitative balance and gait assessments. The number of tandem steps were reduced and the grades of tandem gait were differently distributed in the DCM patients compared to controls (steps, 7.1 ± 3.6 versus 9.9 ± 0.4, p < 0.001; grades of 0/1/2/3/4/5, 1/13/14/15/19 versus 0/0/2/15/38, p < 0.001 in patients with DCM and control respectively). Patients with DCM showed more unstable balance and abnormal gait features including slower velocity, shorter strides, wider bases with increased stance phase of a gait cycle compared to the control group. The grades of tandem gait were correlated with JOA sub-score (r = 0.553, p < 0.001) and the Nurick scale (r = - 0.652, p < 0.001) as well as both balance and gait parameters. In DCM patients, tandem gait was impaired and correlated with severity of gait abnormality. The authors believe that 10-step tandem gait test is an objective and useful screening test for evaluating gait disturbance in patients with DCM.

Strategies for prevention of rod fracture in adult spinal deformity: cobalt chrome rod, accessory rod technique, and lateral lumbar interbody fusion.

OBJECTIVE: Restoring the proper sagittal alignment in adult spinal deformity (ASD) can improve radiological and clinical outcomes, but pseudarthrosis including rod fracture (RF) is a common problematic complication. The purpose of this study was to analyze the methods for reducing the incidence of RF in deformity correction of ASD. METHODS: The authors retrospectively selected 178 consecutive patients (mean age 70.8 years) with lumbar degenerative kyphosis (LDK) who underwent deformity correction with a minimum 2-year follow-up. Patients were classified into the non-RF group (n = 131) and the RF group (n = 47). For predicting the crucial factors of RF, patient factors, radiographic parameters, and surgical factors were analyzed. RESULTS: The overall incidence of RF was 26% (47/178 cases), occurring in 42% (42/100 cases) of pedicle subtraction osteotomy (PSO), 7% (5/67 cases) of lateral lumbar interbody fusion (LLIF) with posterior column osteotomy, 18% (23/129 cases) of cobalt chrome rods, 49% (24/49 cases) of titanium alloy rods, 6% (2/36 cases) placed with the accessory rod technique, and 32% (45/142 cases) placed with the 2-rod technique. There were no significant differences in the incidence of RF regarding patient factors between two groups. While both groups showed severe sagittal imbalance before operation, lumbar lordosis (LL) was more kyphotic and pelvic incidence (PI) minus LL (PI-LL) mismatch was greater in the RF group (p < 0.05). Postoperatively, while LL and PI-LL did not show significant differences between the two groups, LL and sagittal vertical axis correction were greater in the RF group (p < 0.05). Nonetheless, at the last follow-up, the two groups did not show significant differences in radiographic parameters except thoracolumbar junctional angles. As for surgical factors, use of the cobalt chrome rod and the accessory rod technique was significantly greater in the non-RF group (p < 0.05). As for the correction method, PSO was associated with more RFs than the other correction methods, including LLIF (p < 0.05). By logistic regression analysis, PSO, preoperative PI-LL mismatch, and the accessory rod technique were crucial factors for RF. CONCLUSIONS: Greater preoperative sagittal spinopelvic malalignment including preoperative PI-LL mismatch was the crucial risk factor for RF in LDK patients 65 years or older. For restoring and maintaining sagittal alignment, use of the cobalt chrome rod, accessory rod technique, or LLIF was shown to be effective for reducing RF in ASD surgery.

Cervical Radiculopathy Focus on Characteristics and Differential Diagnosis.

Cervical radiculopathy is characterized by neurological dysfunction caused by compression and inflammation of the spinal nerves or nerve roots of the cervical spine. It mainly presents with neck and arm pain, sensory loss, motor dysfunction, and reflex changes according to the dermatomal distribution. The most common causes of cervical radiculopathy are cervical disc herniation and cervical spondylosis. It is important to find the exact symptomatic segment and distinguish between conditions that may mimic certain cervical radicular compression syndromes through meticulous physical examinations and precise reading of radiographs. Non-surgical treatments are recommended as an initial management. Surgery is applicable to patients with intractable or persistent pain despite sufficient conservative management or with severe or progressive neurological deficits. Cervical radiculopathy is treated surgically by anterior and/or posterior approaches. The appropriate choice of surgical treatment should be individualized, considering the patient's main pathophysiology, specific clinical symptoms and radiographic findings thoroughly.

Spino-Pelvic Thresholds for Prevention of Proximal Junctional Kyphosis Following Combined Anterior Column Realignment and Short Posterior Spinal Fusion in Degenerative Lumbar Kyphosis.

OBJECTIVE: To analyze ideal indication for combined anterior column realignment (ACR) with short posterior spinal fusion (PSF) and posterior column osteotomy (PCO) for preventing proximal junctional kyphosis (PJK) in adult spinal deformity (ASD) patients with lower lumbar kyphosis and compensatory thoracolumbar lordosis. METHODS: A retrospective study was conducted. This study included 27 ASD patients (average age of 66.6 years; one male and 26 females) with lower lumbar kyphosis and compensated thoracolumbar lordosis who underwent short PSF with PCO following ACR from 2006 to 2010. The minimum follow-up period was 5 years. The patients were divided into two groups based on the sagittal vertical axis (SVA) of the last follow-up radiographs, and a comparative analysis was performed evaluating spino-pelvic parameters and clinical outcomes including the Oswestry Disability Index (ODI), Visual Analog Scale (VAS), and complications. RESULTS: The mean follow-up time of included patients was 109.7 months, and the mean number of fused segments was 3.7. The uppermost instrumented vertebra was L2 in 18 patients or L3 in nine patients, and lowermost instrumented vertebra was sacrum in all patients. The mean lumbar lordosis (LL) values in the optimal SVA and suboptimal SVA groups were 4.4° and 4.2° preoperatively (P = 0.639), -48.1° and -35° postoperatively (P = 0.007), and -45.2° and -20.7° at the last follow-up (P < 0.05). Overcorrection was seen in seven patients in the optimal SVA group, whereas all of the patients of the suboptimal SVA group were in the category of undercorrection (P = 0.021). Pelvic incidence (PI) of optimal SVA group (<50 mm, n = 16) and suboptimal SVA group (≥50 mm, n = 11) was 44.1° and 53.8° (P = 0.009). The prevalence of PJK was significantly higher in the suboptimal SVA group (P = 0.008), and last follow-up VAS for back pain (P < 0.05), and postoperative and last follow-up ODI (P = 0.002 and P < 0.05) were statistically larger for the suboptimal group than the optimal group. CONCLUSIONS: Combined ACR with short PSF and PCO could effectively prevent sagittal decompensation of PJK and help achieve sagittal balance in the treatment of ASD patients with lower lumbar kyphosis, compensatory thoracolumbar lordosis, and especially low PI (<50°).

Proximal Junctional Kyphosis in Degenerative Sagittal Deformity After Under- and Overcorrection of Lumbar Lordosis: Does Overcorrection of Lumbar Lordosis Instigate PJK?

STUDY DESIGN: Retrospective study. OBJECTIVE: To analyze proximal junctional kyphosis (PJK) occurrence and surgical outcomes according to degree of lumbar lordosis (LL) correction relative to pelvic incidence (PI). In addition, risk factors of PJK including LL and sagittal vertical axis (SVA) correction were investigated. SUMMARY OF BACKGROUND DATA: PJK is a common complication after adult spinal deformity surgery, and many factors are known to be associated with PJK. However, the effect of degree of LL correction on PJK occurrence is not fully understood. METHODS: Eighty-three degenerative sagittal imbalance patients treated with deformity correction and long instrumented fusion to the sacrum with a minimum follow-up of 2 years were studied. Patients were divided into three groups according to their postoperative LL angle relative to PI using the SRS-Schwab classification: Group A (undercorrection, PI-LL> 10°), Group B (ideal correction, -10°

Strategy for obtaining solid fusion at L5-S1 in adult spinal deformity: risk factor analysis for nonunion at L5-S1.

OBJECTIVE: Maintaining lumbosacral (LS) arthrodesis and global sagittal balance after long fusion to the sacrum remains an important issue in the surgical treatment for adult spinal deformity (ASD). The importance and usefulness of LS fixation have been documented, but the optimal surgical long fusion to the sacrum remains a matter for debate. Therefore, the authors performed a retrospective study to evaluate fusion on CT scans and the risk factors for LS pseudarthrosis (nonunion) after long fusion to the sacrum in ASD. METHODS: The authors performed a retrospective study of 59 patients with lumbar degenerative kyphosis (mean age 69.6 years) who underwent surgical correction, including an interbody fusion of the L5-S1, with a minimum 2-year follow-up. Achievement of LS fusion was evaluated by analyzing 3D-CT scans at 3 months, 6 months, 9 months, 1 year, and 2 years after surgery. Patients were classified into a union group (n = 36) and nonunion group (n = 23). Risk factors for nonunion were analyzed, including patient and surgical factors. RESULTS: The overall fusion rate was 61% (36/59). Regarding radiological factors, optimal sagittal balance at the final follow-up significantly differed between two groups. There were no significant differences in terms of patient factors, and no significant differences with respect to the use of pedicle subtraction osteotomy, the number of fused segments, the proportion of anterior versus posterior interbody fusion, S2 alar iliac fixation versus conventional iliac fixation, or loosening of sacral or iliac screws. However, the proportion of metal cages to polyetheretherketone cages and the proportion of sacropelvic fixation were significantly higher in the union group (p = 0.022 and p < 0.05, respectively). CONCLUSIONS: LS junction fusion is crucial for global sagittal balance, and the use of iliac screws in addition to LS interbody fusion using a metal cage improves the outcomes of long fusion surgery for ASD patients.

Is Scapular Stabilization Exercise Effective for Managing Nonspecific Chronic Neck Pain?: A Systematic Review.

Scapular stabilization is thought to have an important role in improving pain and dysfunction around the neck and shoulders, but evidence of this is lacking. We aim to systematically review the effect of a scapular stabilization exercise (SSE) on pain and dysfunction in patients with nonspecific chronic neck pain (NP). We searched the PubMed, EMBASE, CINAHL, and Cochrane Library databases using the terms (NP [MeSH] OR NP OR cervical pain OR neck ache OR cervicalgia) AND (scapular exercise OR periscapular exercise OR SSEs). We included suitable studies that met the study's inclusion criteria. Among the 227 studies identified by our search strategy, a total of four (three randomized controlled studies and one prospective study) met the inclusion criteria. The SSE was intense. It included three sets of 10 repetitions. In most of the studies, the exercises were conducted 3 times per week. Most studies reported that the SSE improved pain and dysfunction in patients with nonspecific chronic NP; however, the reviewed articles did not use the same variables for measurement. Additionally, the sample size was small. Although several studies show that SSE might improve NP and dysfunction, the effects of SSE on pain and dysfunction in the neck region remain unclear because the number of studies was small. Further high-quality studies are necessary to identify the detailed effects of SSE in patients with NP.

Minimally invasive multilevel lateral lumbar interbody fusion with posterior column osteotomy compared with pedicle subtraction osteotomy for adult spinal deformity.

BACKGROUND CONTEXT: Pedicle subtraction osteotomy (PSO) is highly effective as a sagittal correction approach in patients with adult spinal deformity, but relevant issues such as surgical complexity and long-term complications limit its applicability. Recently, minimally invasive techniques have been reported to be useful for surgical treatment of adult spinal deformity; however, few reports have directly compared these techniques with PSO. PURPOSE: The purpose of this study was to evaluate the radiological and clinical efficacies of oblique lateral interbody fusion (OLIF) with posterior column osteotomy (PCO) using stiff rods (6.35-mm cobalt chrome [CoCr]). STUDY DESIGN: Retrospective comparative study. PATIENT SAMPLE: One-hundred six patients (average age 71.3 years) diagnosed with adult spinal deformity presenting with sagittal imbalance for whom follow-up of over 2 years after sagittal correction (between 2013 and 2017) was available. OUTCOME MEASURES: Description and analysis of X-ray, computed tomography scans, operative time, estimated blood loss, and clinical outcomes (Oswestry Disability Index [ODI] and Visual Analog Scale [VAS]). METHODS: A comparative analysis was performed evaluating spinopelvic parameters and clinical outcomes including the ODI, VAS, and complications in patients who underwent PSO (PSO group; n=65) or multilevel prepsoas OLIF combined with PCO and open posterior spinal fusion using 6.35-mm CoCr rods (OLIF group; n=41). The authors have no conflicts of interest to disclose. RESULTS: There were no differences in preoperative spinopelvic parameters between the PSO and OLIF groups. Although no differences were observed between the two groups in terms of postoperative SVA (-12.66 mm vs. -16.44 mm), postoperative lumbar lordosis (-71.46° vs. -72.55°), lumbar lordosis correction (77.96° vs. 73.54°), or postoperative pelvic tilt (9.35° vs. 7.17°), the estimated blood loss was significantly lower in the OLIF group (2824 mL vs. 1736 mL, p<.05). No differences were observed in clinical outcomes (ODI, VAS, and clinical complications), proximal junctional kyphosis, and spinopelvic parameters between the two groups 2 years after surgery. However, pseudarthrosis during the follow-up period, including rod fracture, occurred less frequently in the OLIF group compared with that in the PSO group (p<.05). OLIF was performed from the T12-L1 to L5-S1 regions (124 segments), with an average of three segments per patient. The computed tomography scans immediately after surgery showed an average segmental correction of -18° and 12.9% (16 segments) of 124 segments showed a correction angle of >30°. CONCLUSIONS: Multilevel OLIF with PCO using a stiff rod to treat severe sagittal imbalance resulted in similar levels of sagittal balance and lordosis correction as obtained by PSO. Multilevel OLIF with PCO using a stiff rod can be an effective alternative to PSO for patients with severe sagittal imbalance.

Preliminary report on the flexible rod technique for prevention of proximal junctional kyphosis following long-segment fusion to the sacrum in adult spinal deformity.

OBJECTIVE: The incidence of proximal junctional kyphosis (PJK) after long-segment fixation in patients with adult spinal deformity (ASD) has been reported to range from 17% to 61.7%. Recent studies have reported using "hybrid" techniques in which semirigid fixation is introduced between the fused and flexible segments at the proximal level to allow a more gradual transition. The authors used these hybrid techniques in a clinical setting and analyzed PJK to evaluate the usefulness of the flexible rod (FR) technique. METHODS: The authors retrospectively selected 77 patients with lumbar degenerative kyphosis (LDK) who underwent sagittal correction and long-segment fixation and had follow-up for > 1 year. An FR was used in 30 of the 77 patients. PJK development and spinal sagittal changes were analyzed in the FR and non-FR groups, and the predictive factors of PJK between a PJK group and a non-PJK group were compared. RESULTS: The patient population comprised 77 patients (75 females and 2 males) with a mean (± SD) follow-up of 32.0 ± 12.7 months (36.7 ± 9.8 months in the non-FR group and 16.8 ± 4.7 months in the FR group) and mean (± SD) age of 71.7 ± 5.1 years. Sagittal balance was well maintained at final follow-up (10.5 and 1.5 mm) in the non-FR and FR groups, respectively. Thoracic kyphosis (TK) and lumbar lordosis (LL) were improved in both groups, without significant differences between the two (p > 0.05). PJK occurred in 28 cases (36.4%) in total, 3 (10%) in the FR and 25 (53.2%) in the non-FR group (p < 0.001). Postoperatively, PJK was observed at an average of 8.9 months in the non-FR group and 1 month in the FR group. No significant differences in the incidence of PJK regarding patient factors or radiological parameters were found between the PJK group and non-PJK group (p > 0.05). However, FR (vs non-FR) and interbody fusion except L5-S1 using oblique lumbar interbody fusion (vs non-oblique lumbar interbody fusion), demonstrated a significantly lower PJK prevalence (p < 0.001 and p = 0.044) among the surgical factors. CONCLUSIONS: PJK was reduced after surgical treatment with the FR in the patients with LDK. Solid long-segment fixation and the use of the FR may become another surgical option for spine surgeons who plan and make decisions regarding spine reconstruction surgery for patients with ASD.