Preoperative Scoring System for Prediction of Early Adjacent Vertebral Body Fracture After Balloon Kyphoplasty Using X-Rays Taken in a Non-Weight-Bearing Position.

BACKGROUND: Prevention of adjacent vertebral body fracture (AVF) following balloon kyphoplasty (BKP) is a key challenge. The objective of this study was to develop a scoring system that could be more extensively and effectively used to determine the surgical indications for BKP. METHODS: The study involved 101 patients aged 60 years or older who had undergone BKP. Logistic regression analysis was used to identify risk factors for early AVF within 2 months following BKP. Scoring was based on the odds ratio for risk factors, and cut-off values were determined from the receiver operating characteristics curve. The correlation between the total scores and the incidence of early AVF, and the area under the curve for the logistic regression model predicting early AVF using the scoring system were investigated. RESULTS: 29 cases (28.7%) experienced early AVF after BKP. The scoring system was created as follows: 1) age (<75 years: 0 points (P), ≥75 years: 1P), 2) number of previous vertebral fractures (0: 0P, 1 or more: 2P), and 3) local kyphosis (<7°: 0P, ≥7°: 1P). The total scores were found to be positively correlated with the incidence of early AVF (r = 0.976, P = 0.004). The area under the curve of the scoring system for predicting early AVF was 0.796. The incidence of early AVF was 4.2% at ≤1P and 44.3% at ≥2P (P < 0.001). CONCLUSIONS: A scoring system which can be applied to a broader patient population was developed. In cases where the total score is 2P or more, alternatives to BKP should be considered.

The Relationship Between Global Sagittal Balance and the Incidence of Early Adjacent Vertebral Fractures Following Balloon Kyphoplasty.

BACKGROUND: Recently, it is widely known that global sagittal balance (GSB) influences the postoperative outcome of the spine. The purpose of this study was to investigate the relationship between GSB and the incidence of early adjacent vertebral fracture (AVF) following balloon kyphoplasty (BKP). METHODS: This study included 96 patients (19 males, 77 females, mean age 77.4 ± 5.5 years) who underwent BKP for osteoporotic vertebral fracture and who were over 60-years-old. We investigated the effect of GSB on early AVF within 2 months after surgery. Of the 96 patients, 76 patients (16 males, 60 females, mean age 77.0 ± 5.4) underwent BKP at the thoracolumbar junction (T11-L2) and were investigated independently. After the two-group comparison, logistic regression analysis was performed. RESULTS: During the observation period (18.3 ± 14.7 months), 27 of 96 patients (28.1%) suffered AVF after BKP, and 24 of 96 patients (25.0%) suffered early AVF. In the logistic regression analysis, spinopelvic parameters were not detected as significant risk factors. In cases of BKP at the thoracolumbar junction (T11-L2), 24 of 76 patients (31.6%) suffered AVF after BKP during the observation period (15.3 ± 19.5 months), and 21 of 76 patients (27.6%) suffered early AVF. Logistic regression analysis detected pelvic tilt (PT): odds ratio 1.087 (P = 0.046∗) and local kyphosis: 1.147 (P = 0.003∗) as risk factors for early AVF. The cutoff value was PT≥29° from the receiver operating characteristics curve. CONCLUSIONS: At the thoracolumbar junction (T11-L2), PT ≥29° is one of the risk factors of early AVF following BKP.

Construct Validity and Reliability of the Japanese Version of the Lumbar Stiffness Disability Index.

STUDY DESIGN: Outcome study to determine the construct validity and reliability of the Japanese version of the Lumbar Stiffness Disability Index. OBJECTIVE: The aim of this study was to evaluate the psychometric measurement properties of the Japanese version of the Lumbar Stiffness Disability Index (J-LSDI) following lumbar spinal surgery in order to assess its construct validity and reliability. SUMMARY OF BACKGROUND DATA: The LSDI was designed and validated as a tool to assess functional impacts of lumbar spine stiffness and diminished spinal flexibility. A Japanese version has been developed, but its construct validity and reliability have not been evaluated. METHODS: A Pearson correlation coefficient was calculated using flexion and extension range of motion, Oswestry Disability Index (ODI) and Tampa Scale for Kinesiophobia (TSK) as external standards to evaluate construct validity. An intraclass correlation coefficient (ICC) and a Bland-Altman analysis were used to evaluate test-retest reliability. RESULTS: A total of 244 patients following lumbar spinal surgery participated in the study. Fifty one of the 244 patients participated in the reliability study. The ICC of the J-LSDI for test-retest reliability was 0.89 (95% confidence interval, 0.79-0.93). There was no systematic error found in the results of the Bland-Altman analysis. One hundred ninety-three of the 244 patients participated in the validity study. There were significant correlations between the J-LSDI and trunk flexion range of motion (r = -0.66), extension (r = -0.51), ODI (r = 0.62), and TSK (r = 0.38). CONCLUSION: The construct validity and reliability of the Japanese version of the LSDI were confirmed. The J-LSDI can be used to evaluate lumbar stiffness and associated disability in Japanese patients following lumbar spinal surgery.Level of Evidence: 2.

Preoperative scoring system for predicting early adjacent vertebral fractures after Balloon Kyphoplasty.

BACKGROUND: Adjacent vertebral fracture (AVF) is a major complication following Balloon Kyphoplasty (BKP). There is no scoring system for predicting AVF using only preoperative elements. The purposes of this study were to develop a scoring system for predicting early AVF after BKP based on preoperative factors and to investigate the appropriate surgical indication for BKP. METHODS: Of 220 patients who underwent BKP at a single institution since 2011, 65 patients over the age of 60 who had undergone a standing whole spine X-ray preoperatively were enrolled. Factors affecting the occurrence of early AVF were examined. A scoring system was created consisting of the factors exhibiting significant differences, and the correlation between the total score and the incidence of early AVF was investigated. RESULTS: Twenty of the 65 patients (30.8%) had early AVF. In a univariate analysis, age, previous vertebral fracture, pelvic tilt, and Local kyphosis significantly influenced early AVF. In a multivariate logistic regression analysis, age had an odds ratio of 1.136 (95% CI 1.001-1.289), previous vertebral fractures 4.181 (1.01-17.309), and Local kyphosis 1.103 (1.021-1.191). The scoring system was set as follows: ①Age (<75 years: 0 points(P), 75years≦: 1P), ②The number of previous vertebral fractures (0: 0 P, 1: 1P, 2: 2P, 3 or more: 3P), and ③Local kyphosis (<10°: 0P, 10°â‰¦: 1P). There was a correlation between the total score and the incidence of early AVF (r = 0.812, ∗P = 0.05). The incidence of early AVF was 6.4% (2 cases/31 cases) for a score of ≦1P and 54.5% (18 cases/33 cases) for a score of ≧2P. CONCLUSIONS: There was a correlation between the total score and the incidence of early AVF. A score of 1 point or less may represent the appropriate surgical indication for BKP.

Anatomical Evaluation of the Sacral Hiatus Using Ultrasound Imaging: Factors That Inhibit Needle Insertion During Caudal Epidural Block Procedures.

OBJECTIVE: Caudal epidural blocks often fail due to the difficulty of appropriate needle insertion. This study aimed to evaluate the anatomy of the sacral hiatus using ultrasound imaging. METHODS: This was a retrospective study involving 76 patients with spinal disorders. The following factors were analyzed to see if they affected the palpability of the sacral hiatus: sex, body mass index (BMI), and the morphology of the sacral hiatus on ultrasound imaging. The difficulty of needle insertion and the factors that influenced it were investigated in 28 of the 76 patients, who underwent landmark-based caudal epidural block procedures performed by the same doctor. RESULTS: Among the 76 patients, the mean length of the sacral hiatus was 21.3 ± 5.6 mm, the mean distance from the skin to the sacral cornua was 5.2 ± 3.4 mm, and the mean angle of the sacral hiatus was 16.4 ± 5.5 degrees. Sacral base protrusion was present and absent in 35 and 41 cases, respectively. The sacral hiatus exhibited good and poor palpability in 53 and 23 cases, respectively. The mean distance from the skin to the sacral cornua and BMI were found to significantly influence the palpability of the sacral hiatus. Only sacral base protrusion significantly influenced the difficulty of needle insertion. CONCLUSION: The mean distance from the skin to the sacral cornua and BMI were found to be associated with the palpability of the sacral hiatus, and sacral base protrusion was demonstrated to be associated with the difficulty of needle insertion into the sacral hiatus.

Factors Influencing Interbody Cage Subsidence Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This is a prospective study. OBJECTIVE: The purpose of this study was to analyze the factors influencing subsidence following anterior cervical discectomy and fusion (ACDF) using a stand-alone cage. SUMMARY OF BACKGROUND DATA: The relationship between cage subsidence and cage height and material has been reported in previous studies. METHODS: Clinical and radiologic data from 78 patients, 105 levels, undergoing single-level and 2-level ACDF without plates from 2007 to 2015 were collected prospectively. Patients were followed for at least 12 months after surgery. Radiographs were obtained preoperatively, at 1 week, and at 1, 3, 6, and 12 months postoperatively to determine the presence of fusion and cage subsidence. RESULTS: There was a correlation in cage height and subsidence (Spearman P<0.05). Cage subsidence was significantly shorter in the polyetheretherketone cages than in titanium cages (P<0.05). However, when cage height was <5 mm, the difference between the 2 groups was not significant. Large subsidence (>3 mm) was observed in 17 patients, 20 levels, many of whom exhibited sinking in the first month after surgery. CONCLUSIONS: The greater the cage height, the greater the risk of cage subsidence in ACDF. Polyetheretherketone cages are superior to titanium cages for the maintenance of intervertebral height in cases where cage height is >5.5 mm. LEVEL OF EVIDENCE: Level 3.

Compensatory mechanism of the spine after corrective surgery without lumbar-sacral fixation for traumatic thoracolumbar kyphotic spine deformity.

BACKGROUND: It remains unclear whether long fusion including lumbar-sacral fixation is needed in corrective surgery to obtain good global sagittal balance (GSB) for the treatment of traumatic thoracolumbar kyphotic spine deformity. The purposes of this study were to evaluate compensatory mechanism of the spine after corrective surgery without lumbar-sacral fixation and to evaluate the parameters affecting the achievement of good GSB post-operatively. METHODS: Twenty (20) subjects requiring corrective surgery (distal end of fixation was L3) were included in this study. The radiographic parameters were measured pre-operatively and at one month after surgery. Sagittal Vertical Axis (SVA), Lumber Lordosis angle altered by fracture (fLL), Thoracic Kyphosis angle altered by fracture (fTK), Pelvic Tilt (PT), Sacral Slope (SS), Pelvic Incidence (PI), Segmental Lumbar Lordosis (sLL: L3-S/L4-S), and local kyphotic angle were measured. The correlation between correction of local kyphotic angle (CLA) and the change in radiographic parameters was evaluated. Post-operatively, subjects with SVA<50 mm and PI-fLL<10°were regarded as the "good GSB group (G group). The radiographic parameters affecting the achievement of G group were statistically evaluated. RESULTS: fLL, sLL:L3-S and sLL:L4-S were decreased indirectly because the local kyphosis was corrected directly (CLA: 26.5 ± 8.6°) (P < 0.001). CLA and the change in fLL showed significant correlation (r = 0.821), the regression equation being: Y = -0.63X+3.31 (Y: The change in fLL, X: CLA). The radiographic parameters significantly affecting the achievement of G group were: SVA, PT, PI-fLL, sLL: L3-S, and sLL: L4-S (P < 0.01). CONCLUSION: The main compensatory mechanism was the decrease of lordosis in the lumbar spine. fLL was decreased to approximately 60% of CLA after surgery. SVA was not corrected by the compensatory mechanism.

Prevalence and risk factors of deep vein thrombosis in patients undergoing lumbar spine surgery.

BACKGROUND: Spinal surgery is classified as a moderate risk for DVT. The occurrence of DVT after various spinal surgical procedures was reviewed retrospectively, and the perioperative risk factors in the high-risk group were identified. In addition, the administration of the factor Xa inhibitor to DVT subjects with unstable thrombosis was evaluated to reveal its effectiveness in the prevention of PTE and postoperative complications. METHODS: This study included 588 subjects who underwent lumbar spine surgery. The patient population consisted of the following four groups: the fracture group (F group), the laminectomy group (La group), the TLIF group (T group), and the long fusion group (Lo group). Bilateral lower limb venous ultrasonography was performed on the day before surgery, the day after surgery, and one week after surgery. The incidence of DVT was determined for each group and potential risk factors were evaluated in the group with the highest incidence of DVT. Subjects with DVT who had unstable thrombosis received anticoagulant therapy (factor Xa inhibitor) and their treatment results were assessed. RESULTS: The overall incidence of DVT was 32.3% (190/588). A significantly high incidence of DVT was observed in the Lo group (54.3%; 75/138). Logistic regression and ROC analysis of potential risk factors in the Lo group identified a D-dimer value of 19.5 ug/ml at one week postoperatively as a risk factor of DVT (p = 0.02; odds ratio, 4.09; 95% CI, 2.82-7.88). Overall, 15.8% of subjects (30/190) received anticoagulant therapy. These subjects experienced neither PTE nor epidural hematoma. A follow-up ultrasonography performed at three weeks postoperatively detected the disappearance/resolution of DVT in 86.7% of these subjects (26/30). CONCLUSION: The incidence of DVT varied according to the invasiveness of the procedure. Successful management of DVT hinges on preoperative risk management involving prophylactic treatment and early diagnosis, in order to avoid PTE and other complications.

Risk Factors of Adjacent Segment Disease After Transforaminal Inter-Body Fusion for Degenerative Lumbar Disease.

STUDY DESIGN: A retrospective study. OBJECTIVE: The purpose of this study was to determine the incidence and risk factors of adjacent segment disease (ASD) after transforaminal inter-body fusion (TLIF) for degenerative lumbar disease. SUMMARY OF BACKGROUND DATA: ASD is a major complication after spinal fusion. Many reports have been published concerning the risk factors for ASD after TLIF. A number of quantitative relationships to spino-pelvic parameters have been established. A retrospective cohort study was carried out to investigate spino-pelvic alignment in patients with ASD after TLIF. METHODS: This study evaluated 263 subjects (150 subjects undergoing floating fusion (FF group), and 113 patients undergoing lumbosacral fusion (LF group)) who underwent TLIF from 2009 to 2012. The mean follow-up period was 37.6 months. Several parameters were measured using pre- and postoperative full-length free-standing radiographs, including lumbar lordosis (LL), sacral slope (SS), pelvic incidence (PI), pelvic tilt (PT), and PI-LL. Multivariate logistic regression analysis was performed to evaluate these parameters as potential risk factors of early onset radiographic ASD. RESULTS: Radiographic ASD was found in 65 cases (43.3%) in the FF group, and 49 cases (43.3%) in the LF group. LL improved by 7.5° and 3.9° in each group respectively after TLIF. However, PT worsened by 6.4° in the LF group. When comparing with ASD positive cases and ASD negative cases, a significant difference in preoperative PT was observed in both FF (P = 0.001) and LF groups (P = 0.0001). Logistic regression analysis and receiver operating characteristic analysis revealed that preoperative PT of more than 22.5° was a significant risk factor of the incidence of ASD after TLIF (P = 0.02; odds ratio: 5.1, 95% CI: 1.62-9.03). CONCLUSION: Patients with preoperative sagittal imbalance have a statistically significant increased risk of ASD. The risk of ASD incidence was 5.1 times greater in subjects with preoperative PT of more than 22.5°.

[A Study of Preoperative Chemotherapy with S-1 plus Cisplatin for Advanced Gastric Cancer].

We studied the effects of preoperative chemotherapy with S-1 plus cisplatin for advanced gastric cancer. There were 16 patients who underwent radical surgery with neoadjuvant chemotherapy between 2000 and 2015. The indications for this were advanced gastric cancer with bulky N2 or N3 lymph nodes, or stage above T4a. Seven patients (43%) showed adverse events, all of which were tumors above Grade 3. Response evaluation showed PR in 13 cases (81%). The histopathological evaluation was Grade 0 in 8 patients (50%) and Grade 1a or above in 8 (50%). Death from recurrence within a year occurred in 4 cases, and 7 patients survived with no recurrence for over 5 years. All cases of survivors with no recurrence had a histopathological evaluation of Grade 1 or above. Three cases (75%) with recurrence and death within a year all had with Grade 0 tumors. We concluded that neoadjuvant chemotherapy with S-1 plus cisplatin was effective for advanced gastric cancer and that histopathological evaluation was invaluable for accurate prognosis.

[A Case of Gemcitabine Refractory Lung Metastasis after Distal Pancreatectomy for Pancreatic Cancer, Effectively Treated with S -1 as Second Line Chemotherapy].

A 64-year-old man was diagnosed with pancreatic cancer by abdominal computed tomography (CT). The examination showed a pancreatic tail cancer and a distal pancreatectomy was performed in 2010. Histopathologically, this tumor was a moderately-differentiated tubular adenocarcinoma. He received gemcitabine adjuvant chemotherapy for a year. In 2012, a chest CT scan revealed 4 nodules in the lower left lobe. We diagnosed gemcitabine-refractory lung metastases after distal pancreatectomy for pancreatic cancer. S-1 chemotherapy was administered as a second line chemotherapy for metastatic pancreatic cancer. After 2 courses of this regimen, the lung metastases were reduced. After 6 courses, a clinical complete response was obtained. Four years and 6 months after the operation, the patient is well without any signs of recurrence, and S-1 chemotherapy is still ongoing.

[A Case of Advanced Gastric Cancer with Peritoneal Dissemination Effectively Treated with S-1 and Docetaxel Combination Chemotherapy].

A 72-year-old man underwent surgery for advanced gastric cancer. Systemic chemotherapy was started, using a regimen of S-1/CDDP for 4 courses, followed by 8 courses of S-1. Three years and 8 months after the surgery, abdominal CT demonstrated ascites, and the serum CA19-9 level was abnormally high (1,165.1 U/mL). Adenocarcinoma cells were found in the ascites. Treatment with S-1/docetaxel (DOC) was started. After 10 courses, the ascites disappeared and the serum CA19-9 value returned to normal. Four years and 7 months after the operation, the patient has been in good health, with no signs of recurrence.

[A Case of Advanced Gastric Cancer with Long-Term Survival after Chemotherapy with Combined S-1 and CPT-11].

Here, we report a 54-year-old man diagnosed with type 3 advanced gastric cancer who underwent a total gastrectomy and splenectomy plus D2 lymphadenectomy. The pathologic diagnosis was Stage Ⅳ (T3N0H0P0CY1M1). Sixteen courses of combined S-1/CPT-11 chemotherapy were completed, at which time the CPT-11 was discontinued because of malaise, and S-1 alone was continued for a year. The patient is well and has been recurrence-free for 7 years. Thus, he is considered a long- term survivor who was treated with combination S-1/CPT-11 chemotherapy.

[A Case of Colon Cancer with Multiple Liver Metastases Successfully Treated with Capecitabine/Oxaliplatin plus Bevacizumab].

A 69-year-old woman was diagnosed with descending colon cancer with multiple liver metastases, and a left hemicolectomy was performed. The patient was treated with capecitabine/oxaliplatin (CapeOX) plus bevacizumab (Bmab). After 5 courses of chemotherapy, the number and size of liver metastases remarkably reduced, and after the 12th course, because of peripheral neuropathy, a "stop-and-go"fashion of administering oxaliplatin (L-OHP) was initiated. After 14 courses, the liver metastases had disappeared. After the 33rd course of L-OHP treatment, the patient started receiving capecitabine therapy. The patient is recurrence-free 3 years after surgery, 14 months after achieving a complete response (CR). We report a case of long-term CR after surgery for descending colon cancer with multiple liver metastases, followed by a "stop-and-go" method of administering L-OHP or CapeOX plus Bmab therapy.

[Two Cases of Liver Metastasis from Pancreatic Cancer with a Complete Response Owing to Chemotherapy].

Case 1: The patient was a 42-year-old man who was diagnosed with intraductal papillary-mucinous carcinoma with liver metastasis. After S-1+gemcitabine and S-1 chemotherapy, the liver metastasis had disappeared and we performed a pancreaticoduodenectomy( PD). Case 2: The patient was a 70-year-old woman who was diagnosed with pancreatic cancer with liver metastasis. After gemcitabine chemotherapy, the liver metastasis had disappeared and we performed a PD. The prognosis of pancreatic cancer is dismal compared to other types of cancer, and for a Stage Ⅳb cancers, the 5-year survival rate is reported to be approximately 3%. We report 2 cases of liver metastases from pancreatic cancer that disappeared in response to chemotherapy. Both patients underwent primary tumor resection after chemotherapy and experienced long-term survival.

[A case of gastric cancer with N2 lymph node metastasis and pancreatic invasion effectively treated with docetax-el/S-1 as a neoadjuvant chemotherapy].

A 74-year-old man was diagnosed with advanced gastric cancer(cStage III B). Laparotomy showed N2 lymph node metastasis and pancreatic invasion. Radical resection appeared impossible and was thus not performed. Chemotherapy consisting of a combination of S-1(80mg/m 2, 2-week administration and 1-week rest), and docetaxel(40mg/m2day 1)was administered with the expectation of tumor downstaging. A partial response(PR)was obtained after five courses of this regimen in which the primary lesion and lymph node swelling remarkably improved. Total gastrectomy, splenectomy, partial colectomy, and D2 lymph node dissection were then performed. Pathological analysis revealed very few cancer cells in the primary lesion and that the lymph nodes had become scarred and fibrotic. The histological appearance was judged to be grade 2 and the final diagnosis was T1N0H0P0CY0M0, fStage I A, curability A. Currently, more than 6 years and 4 months after the operation, the patient is alive without any evidence of recurrence. Thus, docetaxel/S-1 combination therapy was an effective neoadjuvant chemotherapy for this case of advanced gastric cancer.

[A case of rectal cancer with sacrum metastasis treated with S-1 leading to a complete response].

The patient is a 47-year-old female. She had undergone abdominoperineal resection for rectal cancer at 39 years of age. Two years and 9 months after surgery, she was diagnosed with a vagina invasion. Radiation therapy and chemotherapy (UFT/ LV) were performed. After 4 courses of UFT/LV, a complete response (CR) was noted. Four years and 3 months after surgery, she was diagnosed with a sacrum metastasis. Chemotherapy with S-1 was performed. After 2 courses of S-1, a CR was noted. There has been no recurrence sign to date.

Signet ring cell carcinoma of the ampulla of vater. A case report.

CONTEXT: Signet ring cell carcinoma of the ampulla of Vater is extremely rare and only 12 cases have previously been described in the English language literature. We report a case of advanced signet ring cell carcinoma of the ampulla of Vater, with invasion of the duodenum and pancreas. CASE REPORT: A 59-year-old man presented at a local hospital with upper abdominal pain and icterus. Obstructive jaundice was diagnosed and he was referred to our hospital. Abdominal computed tomography showed dilatation of the common bile duct and the pancreatic duct. Duodenoscopy indicated an irregularly shaped erosion on the ampulla of Vater. Histological examination of a biopsy revealed adenocarcinoma. Duodenography revealed irregularity of the second portion of the duodenum wall. The diagnosis was carcinoma of the ampulla of Vater, and a pancreaticoduodenectomy was performed. The histopathological findings detected signet ring cell carcinoma. CONCLUSION: Although several cases have been reported, the detailed clinicopathological features and prognosis are not clear. Additional reports are warranted.