Prevalence and distribution of Schmorl node and endplate signal change, and correlation with disc degeneration in a population-based cohort: the Wakayama Spine Study.

PURPOSE: Degenerative spinal conditions, including disc degeneration (DD), Schmorl nodes (SN), and endplate signal changes (ESC), are pervasive age-associated phenomena that critically affect spinal health. Despite their prevalence, a comprehensive exploration of their distribution and correlations is lacking. This study examined the prevalence, distribution, and correlation of DD, SN, and ESC across the entire spine in a population-based cohort. METHODS: The Wakayama Spine Study included 975 participants (324 men, mean age 67.2 years; 651 women, mean age 66.0 years). Magnetic resonance imaging (MRI) was used to evaluate the intervertebral space from C2/3 to L5/S1. DD was classified using Pfirrmann's system, ESC was identified by diffuse high-intensity signal changes on the endplates, and SN was defined as a herniation pit with a hypointense signal. We assessed the prevalence and distribution of SN, ESC, and DD across the entire spine. The correlations among these factors were examined. RESULTS: Prevalence of ≥ 1 SN over the entire spine was 71% in men and 77% in women, while prevalence of ≥ 1 ESC was 57.9% in men and 56.3% in women. The prevalence of ESC and SN in the thoracic region was the highest among the three regions in both sexes. Positive linear correlations were observed between the number of SN and DD (r = 0.41, p < 0.001) and the number of ESC and DD (r = 0.40, p < 0.001), but weak correlations were found between the number of SN and ESC (r = 0.29, p < 0.001). CONCLUSION: The prevalence and distribution of SN and ESC over the entire spine were observed, and correlations between SN, ESC, and DD were established. This population-based cohort study provides a comprehensive analysis of these factors.

Association between modic changes, disc degeneration, and pelvic incidence-lumbar lordosis mismatch in a large population based cohort: the Wakayama spine study.

PURPOSE: Sagittal plane alignment is crucial for treating spinal malalignment and low back pain. Pelvic incidence-lumbar lordosis (PI-LL) mismatch is commonly used to evaluate clinical outcomes in patients with sagittal malalignment. The association between PI-LL mismatch and changes surrounding the intervertebral disc is very important to understand the compensatory mechanisms involved. This study aimed to examine the association between PI-LL mismatch and magnetic resonance imaging (MRI) changes surrounding the intervertebral disc in a large population-based cohort. METHODS: We evaluated participants from the second Wakayama Spine Study, recruiting the general population aged 20 years or older, irrespective of sex, who were registered residents in one region in 2014. In total, 857 individuals underwent an MRI of the whole spine; however, 43 MRI results were not included due to incomplete or inadequate quality images. PI-LL mismatch was defined as > 11°. We compared the MRI changes, such as Modic change (MC), disc degeneration (DD), and high-intensity zones (HIZ), between PI-LL mismatch and non-PI-LL mismatch groups. Multivariate logistic regression analysis was conducted to determine the association between the MRI changes and PI-LL mismatch with adjustment for age, sex, and body mass index in the lumbar region and at each level. RESULTS: A total of 795 participants (243 men, 552 women, mean age 63.5 ± 13.1 years old) were evaluated; 181 were included in the PI-LL mismatch group. MC and DD in the lumbar region were significantly higher in the PI-LL mismatch group. MC in the lumbar region was significantly associated with PI-LL mismatch (odds ratio (OR); 1.81, 95% confidence interval (CI) 1.2-2.7). MC at each level was significantly associated with PI-LL mismatch (OR; 1.7-1.9, 95%CI 1.1-3.2), and DD at L1/2, L3/4, and L4/5 was associated with PI-LL mismatch (OR; 2.0- 2.4. 95%CI 1.2-3.9). CONCLUSION: MC and DD were significantly associated with PI-LL mismatch. Therefore, profiling MC may be helpful in improving the targeted treatment of LBP associated with the adult spinal deformity.

Spinopelvic fusion surgery from lower thoracic spine to pelvis increased hip joint moment-motion analysis.

PURPOSE: Spinal fusion surgery is often performed with pelvic fixation to prevent distal junctional kyphosis. The inclusion of spinopelvic fixation has been reported to induce progression of hip joint arthropathy in a radiographic follow-up study. However, its biomechanical mechanism has not yet been elucidated. This study aimed to compare the changes in hip joint moment before and after spinal fusion surgery. METHODS: This study was an observational study and included nine patients (eight women and one man) who were scheduled to undergo spinopelvic fusion surgery. We calculated the three-dimensional external joint moments of the hip during gait, standing, and climbing stairs before and 1 year after surgery. RESULTS: During gait, the maximum extension moment was 0.51 ± 0.29 and 0.63 ± 0.40 before and after spinopelvic fusion surgery (p = 0.011), and maximum abduction moment was 0.60 ± 0.33 and 0.83 ± 0.34 before and after surgery (p = 0.004), respectively. During standing, maximum extension moment was 0.76 ± 0.32 and 1.04 ± 0.21 before and after spinopelvic fusion surgery (p = 0.0026), and maximum abduction moment was 0.12 ± 0.20 and 0.36 ± 0.22 before and after surgery (p = 0.0005), respectively. During climbing stairs, maximum extension moment was - 0.31 ± 0.30 and - 0.48 ± 0.15 before and after spinopelvic fusion surgery (p = 0.040), and maximum abduction moment was 0.023 ± 0.18 and - 0.02 ± 0.13 before and after surgery (p = 0.038), respectively. CONCLUSION: This study revealed that hip joint flexion-extension and abduction-adduction moments increased after spinopelvic fixation surgery in the postures of standing, walking, and climbing stairs. The mechanism was considered to be adjacent joint disease after spinopelvic fusion surgery including sacroiliac joint fixation.

Dynamic cord compression induced by proximal junctional failure and loose pedicle screws after thoracolumbar fusion surgery: a case report.

BACKGROUND: One of the common mechanical complications following spinal fusion surgery is proximal junctional failure (PJF). The incidence of neurological deficit associated with PJF has been poorly described in the literature. Here, we report a case in which numbness in the lower extremities was recognized as the first symptom, but the discrepancy in the imaging findings made PJF difficult to diagnose. METHODS: A 71-year-old female underwent corrective fusion surgery. Three weeks later, she complained of persistent right leg numbness. Standing X-ray showed the back-out of the pedicle screws (PSs) in the upper instrumented vertebra (UIV), but there was no obvious evidence of cord compression on computed tomography (CT), which caused the delay of diagnosis. Five weeks later, magnetic resonance image (MRI) did not show cord compression on an axial view, but there were signal changes in the spinal cord. RESULTS: The first reason for the delayed diagnosis was the lack of awareness that leg numbness could occur as the first symptom of PJF. The second problem was the lack of evidence for spinal cord compression in various imaging tests. Loosened PSs were dislocated on standing, but were back to their original position on supine position. In our case, these contradictory images led to a delay in diagnosis. CONCLUSION: Loosened PSs caused dynamic cord compression due to repeated deviation and reduction. Supine and standing radiographs may be an important tool in the diagnosis of PJF induced by dynamic cord compression.

Ultrasonography is an effective tool for the evaluation of traumatic vertebral artery injuries distal to fourth cervical vertebra in the emergency room.

BACKGROUND: This study aimed to determine the feasibility of ultrasonography in the assessment of cervical vertebral artery (VA) injury as an alternative to computed tomography angiography (CTA) in the emergency room. METHODS: We analyzed 50 VAs from 25 consecutive patients with cervical spine injury that had been admitted to our emergency room. Ultrasonography and CTA were performed to assess the VA in patients with cervical spine injury. We examined the sensitivity and specificity of ultrasonography compared with CTA. RESULTS: Among these VAs, six were occluded on CTA. The agreement between ultrasonography and CTA was 98% (49/50) with 0.92 Cohen's Kappa index. The sensitivity, specificity, and positive and negative predictive values of ultrasonography were 100%, 97.7%, 85.7%, and 100%, respectively. In one case with hypoplastic VA, the detection of flow in the VA by ultrasonography differed from detection by CTA. Meanwhile, there were two cases in which VAs entered at C5 transverse foramen rather than at C6 level. However, ultrasonography could detect the blood flow in these VAs. CONCLUSIONS: Ultrasonography had a sensitivity of 100% compared with CTA in assessment of the VA. Ultrasonography can be used as an initial screening test for VA injury in the emergency room.

Clinical and radiographic characteristics of increased signal intensity of the spinal cord at the vertebral body level in patients with cervical myelopathy.

BACKGROUND: Increased signal intensity (ISI) is usually recognized at the disc level of the responsible lesion in the patients with cervical myelopathy. However, it is occasionally seen at the vertebral body level, below the level of compression. We aimed to investigate the clinical significance and the radiographic characteristics of ISI at the vertebral body level. METHODS: This retrospective study included 135 patients with cervical spondylotic myelopathy who underwent surgery and with local ISI. We measured the local and C2-7 angle at flexion, neutral, and extension. We also evaluated the local range of motion (ROM) and C2-7 ROM. The patients were classified into group D (ISI at disc level) and group B (ISI at vertebral body level). RESULTS: The prevalence was 80.7% (109/135) and 19.3% (26/135) for groups D and B, respectively. Local angle at flexion and neutral were more kyphotic in group B than in group D. The local ROM was larger in group B than in group D. Moreover, C2-7 angle at flexion, neutral and extension were more kyphotic in group B than in group D. Two years later, local angle at flexion, neutral, and extension were also kyphotic in group B than group D; however, local and C2-7 ROM was not significantly different between the two groups. There was no significant difference of clinical outcomes 2 years postoperatively between both groups. CONCLUSIONS: Group B was associated with the kyphotic alignment and local greater ROM, compared to group D. As the spinal cord is withdrawn in flexion, the ISI lesion at vertebral body might be displaced towards the disc level, which impacted by the anterior components of the vertebrae. ISI at the vertebral body level might be related to cord compression or stretching at flexion position. This should be different from the conventionally held pincer-mechanism concept.

A nationwide multicenter study of the cost effectiveness of five leading drugs for pharmacological management of cervicobrachial symptoms.

BACKGROUND: Cervicobrachial pain frequently affects the quality of life (QOL) of the general public and has a significant economic impact on the health care systems of various countries. There are a number of treatment options for this disease, including widely-used drug therapy, but the effectiveness of each option is indeterminate, and there have been no published cost-effectiveness analysis studies so far. This prospective observational study aimed to examine the cost-effectiveness of drug treatment for cervicobrachial symptoms. METHODS: A 6-month medication regimen for each of five frequently-prescribed drugs for cervicobrachial symptoms was administered to 322 patients at 24 centers in Japan. Outcome measures, including of the EuroQol Group 5D, Short Form-8, and Visual Analog Scale (VAS), were investigated at baseline and every month thereafter. Incremental cost-effectiveness ratios (ICERs) of the drug cost to quality-adjusted life years (QALYs) were calculated. A stratified analysis of patient characteristics was also performed to identify baseline factors potentially affecting cost-effectiveness. RESULTS: The ICER of entire drug treatment for cervicobrachial symptoms was 7,491,640 yen. Compared with the reference willingness-to-pay, the ICER was assumed to not be cost-effective. A certain number of QALYs were gained during the first 3 months after the treatment intervention, but almost no QALYs were gained during the following 3 months. Stratified analysis showed that cost-effectiveness was extremely low for patients with high baseline VAS and high QOL. CONCLUSIONS: The available medications for cervicobrachial symptoms did not have excellent cost-effectiveness. Although a certain number of QALYs were gained during the first 3 months after medication, no QALYs were gained in the latter half of the study period, suggesting that it is not advisable to continue the medication needlessly. LEVEL OF EVIDENCE: II, prospective cohort study.

A novel technique using ultrasonography in upper airway management after anterior cervical decompression and fusion.

BACKGROUND: Airway complications are the most serious complications after anterior cervical decompression and fusion (ACDF) and can have devastating consequences if their detection and intervention are delayed. Plain radiography is useful for predicting the risk of dyspnea by permitting the comparison of the prevertebral soft tissue (PST) thickness before and after surgery. However, it entails frequent radiation exposure and is inconvenient. Therefore, we aimed to overcome these problems by using ultrasonography to evaluate the PST and upper airway after ACDF and investigate the compatibility between X-ray and ultrasonography for PST evaluation. METHODS: We included 11 radiculopathy/myelopathy patients who underwent ACDF involving C5/6, C6/7, or both segments. The condition of the PST and upper airway was evaluated over 14 days. The Bland-Altman method was used to evaluate the degree of agreement between the PST values obtained using radiography versus ultrasonography. The Pearson correlation coefficient was used to determine the relationship between the PST measurement methods. Single-level and double-level ACDF were performed in 8 and 3 cases, respectively. RESULTS: PST and upper airway thickness peaked on postoperative day 3, with no airway complications. The Bland-Altman bias was within the prespecified clinically nonsignificant range: 0.13 ± 0.36 mm (95% confidence interval 0.04-0.22 mm). Ultrasonography effectively captured post-ACDF changes in the PST and upper airway thickness and detected airway edema. CONCLUSIONS: Ultrasonography can help in the continuous assessment of the PST and the upper airway as it is simple and has no risk of radiation exposure risk. Therefore, ultrasonography is more clinically useful to evaluate the PST than radiography from the viewpoint of invasiveness and convenience.

S2 alar-iliac screw loosening as a preventive factor for hip joint osteoarthritis after adult spinal deformity surgery: a case-control study.

PURPOSE: This study aimed to evaluate the progression of hip pathology and risk factors after ASD surgery. METHODS: This case-control study enrolled 123 patients (246 hips); seven hips underwent hip arthroplasty were excluded. We measured the center-edge (CE) angle, joint space width (JSW), and Kellgren-Lawrence (KL) grade. We defined a CE angle˂25° as developmental dysplasia of the hip (DDH). We evaluated S2 alar-iliac (AI) screw loosening at final follow-up. RESULTS: The annual decrease in the JSW was 0.31 mm up to 1 year, and 0.13 mm after 1 year (p = 0.001). KL grade progression occurred in 24 hips (10.0%; group P), while no progression occurred in 215 (90.0%; group N) hips. Nonparametric analysis between groups P and N revealed that significant differences were observed in sex, DDH, KL grade, ratio of S2AI screw fixation at baseline, and ratio of S2AI screw loosening at final follow-up. Multiple logistic regression analysis revealed that DDH (p = 0.018, odds ratio (OR) = 3.0, 95%CI = 1.2-7.3), baseline KL grade (p < 0.0001, OR = 37.7, 95%CI = 7.0-203.2), and S2AI screw fixation (p = 0.035, OR = 3.4, 95%CI = 1.1-10.4) were significant factors. We performed sub-analysis to elucidate the relationship between screw loosening and hip osteoarthritis in 131 hips that underwent S2AI screw fixation. Non-loosening of the S2AI screw was a significant factor for KL grade progression (p < 0.0001, OR = 8.9, 95%CI = 3.0-26.4). CONCLUSION: This study identified the prevalence and risk factors for the progression of hip osteoarthritis after ASD surgery. Physicians need to pay attention to the hip joint pathology after ASD surgery.

Importance of physiological age in determining indications for adult spinal deformity surgery in patients over 75 years of age: a propensity score matching analysis.

PURPOSE: Physiologically, people age at different rates, which leads to a discrepancy between physiological and chronological age. Physiological age should be a priority when considering the indications for adult spinal deformity (ASD) surgery. The primary objective of this study was to determine the characteristics of the postoperative course, surgical outcomes, and complication rates to extend the healthy life expectancy of older ASD patients (≥ 75 years). The secondary objective was to clarify the importance of physiological age in the surgical treatment of older ASD patients, considering frailty. METHODS: A retrospective review of 109 consecutive patients aged ≥ 65 years with symptomatic ASD who underwent a corrective long fusion with lateral interbody fusion from the lower thoracic spine to the pelvis from 2015 to 2019 was conducted. Patients were classified into two groups according to age (group Y [65-74 years], group O [≥ 75 years]) and further divided into four groups according to the ASD-frailty index score (Y-F, Y-NF, O-F, and O-NF groups). To account for potential risk factors for perioperative course characteristics, complication rates, and surgical outcomes, patients from the database were subjected to propensity score matching based on sex, BMI, and preoperative sagittal spinal alignment (C7 sagittal vertical axis, pelvic incidence-lumbar lordosis, and pelvic tilt). Clinical outcomes were evaluated 2 years postoperatively, using three patient-reported outcome measures of health-related quality of life: the Oswestry Disability Index, Scoliosis Research Society questionnaire (SRS-22), and Short Form 36 (SF-36). Additionally, the postoperative time-to-first ambulation, as well as minor, major, and mechanical complications, were evaluated. RESULTS: In the comparison between Y and O groups, patients in group O were at a higher risk of minor complications (delirium and urinary tract infection). In contrast, other surgical outcomes of group O were comparable to those of group Y, except for SRS-22 (satisfaction) and time to ambulation after surgery, with better outcomes in Group O. Patients in the O-NF group had better postoperative outcomes (time to ambulation after surgery, SRS-22 (function, self-image, satisfaction), SF-36 [PCS]) than those in the Y-F group. CONCLUSIONS: Older age warrants monitoring of minor complications in the postoperative management of patients. However, the outcomes of ASD surgery depended more on frailty than on chronological age. Older ASD patients without frailty might tolerate corrective surgery and have satisfactory outcomes when minimally invasive techniques are used. Physiological age is more important than chronological age when determining the indications for surgery in older patients with ASD.

Lateral interbody release for fused vertebrae via transpsoas approach in adult spinal deformity surgery: a preliminary report of radiographic and clinical outcomes.

BACKGROUND: Lateral interbody release (LIR) via a transpsoas lateral approach is a surgical strategy to address degenerative lumbar scoliosis (DLS) patients with anterior autofusion of vertebral segments. This study aimed to characterize the clinical and radiographic outcomes of this lumbar reconstruction strategy using LIR to achieve anterior column correction. METHODS: Data for 21 fused vertebrae in 17 consecutive patients who underwent LIR between January 2014 and March 2020 were reviewed. Demographic and intraoperative data were recorded. Radiographic parameters were assessed preoperatively and at final follow-up, including segmental lordotic angle (SLA), segmental coronal angle (SCA), bone union rate, pelvic incidence (PI), lumbar lordosis (LL), pelvic tilt, sacral slope, PI-LL mismatch, sagittal vertical axis, Cobb angle, and deviation of the C7 plumb line from the central sacral vertical line. Clinical outcomes were evaluated using Oswestry Disability Index (ODI), visual analog scale (VAS) scores for low back and leg pain, and the short form 36 health survey questionnaire (SF-36) postoperatively and at final follow-up. Complications were also assessed. RESULTS: Mean patient age was 70.3 ± 4.8 years and all patients were female. Average follow-up period was 28.4 ± 15.3 months. Average procedural time to perform LIR was 21.3 ± 9.7 min and was not significantly different from traditional lateral interbody fusion at other levels. Blood loss per single segment during LIR was 38.7 ± 53.2 mL. Fusion rate was 100.0% in this cohort. SLA improved significantly from - 7.6 ± 9.2 degrees preoperatively to 7.0 ± 8.8 degrees at final observation and SCA improved significantly from 19.1 ± 7.8 degrees preoperatively to 8.7 ± 5.9 degrees at final observation (P < 0.0001, and < 0.0001, respectively). All spinopelvic and coronal parameters, as well as ODI and VAS, improved significantly. Incidence of peri- and postoperative complications such as iliopsoas muscle weakness and leg numbness in patients who underwent LIR was as much as XLIF. Incidence of postoperative mechanical failure following LIR was also similar to XLIF. Reoperation rate was 11.8%. However, there were no reoperations associated with LIR segments. CONCLUSIONS: The LIR technique for anterior column realignment of fused vertebrae in the context of severe ASD may be an option of a safe and effective surgical strategy.

Adjacent segment disease on hip joint as a complication of spinal fusion surgery including sacroiliac joint fixation.

PURPOSE: Recently, the number of adult spinal deformity surgeries including sacroiliac joint fixation (SIJF) by using an S2 alar iliac screw or iliac screw has increased to avoid the distal junctional failure. However, we occasionally experienced patients who suffered from hip pain after a long instrumented spinal fusion. We hypothesized that long spinal fusion surgery including SIJF influenced the hip joint as an adjacent joint. The aim of this paper was to evaluate the association between spinal deformity surgery including SIJF and radiographic progression of hip osteoarthritis (OA). METHODS: This study was retrospective cohort study. In total, 118 patients who underwent spinal fusion surgery at single center from January 2013 to August 2018 were included. We measured joint space width (JSW) at central space of the hip joint. We defined reduction of more than 0.5 mm/year in JSW as hip OA progression. The patients were divided into two groups depending on either a progression of hip osteoarthritis (Group P), or no progression (Group N). RESULTS: The number of patients in Group P and Group N was 47 and 71, respectively. Factor that was statistically significant for hip OA was SIJF (p = 0.0065, odds ratio = 7.1, 95% confidence interval = 1.6-31.6). There were no other significant differences by the multiple logistic regression analysis. CONCLUSION: This study identified spinal fixation surgery that includes SIJF as a predictor for radiographic progression of hip OA over 12 months. We should pay attention to hip joint lesions after adult spinal deformity surgery, including SIJF.

Improving effect of microendoscopic decompression surgery on low back pain in patients with lumbar spinal stenosis and predictive factors of postoperative residual low back pain: a single-center retrospective study.

BACKGROUND: Although there are reports on the effectiveness of microendoscopic laminotomy using a spinal endoscope as decompression surgery for lumbar spinal stenosis, predicting the improvement of low back pain (LBP) still poses a challenge, and no clear index has been established. This study aimed to investigate whether microendoscopic laminotomy for lumbar spinal stenosis improves low back pain and determine the preoperative predictors of residual LBP. METHODS: In this single-center retrospective study, we examined 202 consecutive patients who underwent microendoscopic laminotomy for lumbar spinal stenosis with a preoperative visual analog scale (VAS) score for LBP of ≥40 mm. The lumbar spine Japanese Orthopaedic Association (JOA), and VAS scores for LBP, leg pain (LP), and leg numbness (LN) were examined before and at 1 year after surgery. Patients with a 1-year postoperative LBP-VAS of ≥25 mm composed the residual LBP group. The preoperative predictive factors associated with postoperative residual LBP were analyzed. RESULTS: JOA scores improved from 14.1 preoperatively to 20.2 postoperatively (p < 0.001), LBP-VAS improved from 66.7 to 29.7 mm (p < 0.001), LP-VAS improved from 63.8 to 31.2 mm (p < 0.001), and LN-VAS improved from 63.3 to 34.2 mm (p < 0.001). Ninety-eight patients (48.5%) had a postoperative LBP-VAS of ≥25 mm. Multiple logistic regression analysis revealed that Modic type 1 change (odds ratio [OR], 5.61; 95% confidence interval [CI], 1.68-18.68; p = 0.005), preoperative VAS for LBP ≥ 70 mm (OR, 2.19; 95% CI, 1.17-4.08; p = 0.014), and female sex (OR, 1.98; 95% CI, 1.09-3.89; p = 0.047) were preoperative predictors of residual LBP. CONCLUSION: Microendoscopic decompression surgery had an ameliorating effect on LBP in lumbar spinal stenosis. Modic type 1 change, preoperative VAS for LBP, and female sex were predictors of postoperative residual LBP, which may be a useful index for surgical procedure selection.

Sagittal imbalance of the spine-pelvis-lower extremity axis associated with back-related disability.

BACKGROUND: The impact of sagittal imbalance in patients has been reported in LBP and LBP-related disabilities due to spinopelvic imbalance. However, no reports investigating the spine-pelvis-lower extremity axis using lateral images have been reported thus far. This study introduced a novel parameter of the spine-pelvis-lower extremity axis and evaluated whether this parameter was related to symptoms. METHODS: A total of 343 subjects were included in this cross-sectional study. Standing spine-pelvis and pelvis-lower extremity radiographs were obtained to assess the sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), lumbar lordosis, and thoracic kyphosis. The sacral-knee distance (SKD) (i.e., distance from the anterior femoral condyle to the vertical axis at the upper posterior edge of S1 body) was measured. Furthermore, the SVA/SKD ratio was calculated for global balance. Subjects were divided into leg compensated (LC; SVA/SKD ratio <0.8) and decompensated (LD; SVA/SKD ratio ≥0.8) groups. The SVA was divided into balanced spine (BS; SVA ≤40 mm) and imbalanced spine (IS; SVA >40 mm) groups. All individuals were classified into LC + BS, LC + IS, LD + BS, and LD + IS groups. The relationships among the four groups and low back pain (LBP), Oswestry Disability Index (ODI), and knee pain were examined. RESULTS: SKD was significantly correlated with SVA, SS, PI, PT, and knee-femoral angle. ODI was significantly higher in the LC + IS group than in the LD + BS group (p < 0.05). Knee pain prevalence was significantly higher in the LC + IS and LC + BS groups than in the LD + IS group (p < 0.05). CONCLUSION: SVA/SKD ratio is useful for evaluating global alignment. Our findings are significant because they highlight the importance of SKD with respect to knee pain, LBP, and LBP- related disabilities.

Timely intubation with early prediction of respiratory exacerbation in acute traumatic cervical spinal cord injury.

BACKGROUND: Early routine intubation in motor-complete cervical spinal cord injury (CSCI) above the C5 level is a conventional protocol to prevent unexpected respiratory exacerbation (RE). However, in the context of recent advances in multidisciplinary respiratory management, the absolute indication for intubation in patients with CSCI based on initial neurologic assessment is controversial because of the drawbacks of intubation. This study aimed to redetermine the most important predictor of RE following CSCI after admission without routine intubation among patients admitted with motor-complete injury and/or injury above the C5 level to ensure timely intubation. METHODS: We performed a retrospective review of patients with acute traumatic CSCI admitted to our hospital without an initial routine intubation protocol from January 2013 to December 2017. CSCI patients who developed RE (defined as unexpected emergent intubation for respiratory resuscitation) were compared with those who did not. Baseline characteristics and severity of trauma data were collected. Univariate analyses were performed to compare treatment data and clinical outcomes between the two groups. Further, multivariate logistic regression was performed with clinically important independent variables: motor-complete injury, neurologic level above C5, atelectasis, and copious airway secretion (CAS). RESULTS: Among 58 patients with CSCI, 35 (60.3%) required post-injury intubation and 1 (1.7%) died during hospitalization. Thirteen (22.4%) had RE 3.5 days (mean) post-injury; 3 (37.5%) of eight patients with motor-complete CSCI above C5 developed RE. Eleven of the 27 (40.7%) patients with motor-complete injury and five of the 22 (22.7%) patients with neurologic injury above C5 required emergency intubation at RE. Three of the eight CSCI patients with both risk factors (motor-complete injury above C5) resulted in emergent RE intubation (37.5%). CAS was an independent predictor for RE (odds ratio 7.19, 95% confidence interval 1.48-42.72, P = 0.0144) in multivariate analyses. CONCLUSION: Timely intubation post-CSCI based on close attention to CAS during the acute 3-day phase may prevent RE and reduce unnecessary invasive airway control even without immediate routine intubation in motor-complete injury above C5.

Preoperative psychological factors affecting surgical satisfaction of elderly patients with lumbar spinal stenosis.

OBJECTIVE: The objective of this observational study was to investigate the effects of preoperative psychological factors on short-term patient satisfaction with surgery in elderly patients with lumbar spinal stenosis (LSS). METHODS: Surgery was performed on 90 elderly patients with clinically and radiologically defined LSS: mean age at surgery, 73 years; 46 men and 44 women. Patients completed questionnaires before surgery and 1 year postoperatively. They used a self-administered the Roland Morris Disability Questionnaire (RDQ), the Japanese Orthopaedic Association Back Pain Questionnaire (JOABPEQ), MOS 36-Item Short-Form Health Survey (SF-36), and satisfaction for surgery (VAS) were completed. At baseline, psychological factors were assessed using the Self-Rating Questionnaire for Depression (SRQ-D), Hospital Anxiety and Depression scale (HADS), Pain Catastrophizing Scale (PCS), Pain Anxiety Symptoms Scale-20, and Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP). At follow-up, patient satisfaction was evaluated using 2 items: (1) satisfaction with surgery and (2) Would you undergo the same surgery again?. RESULTS: Satisfaction item 1 correlated negatively with the VAS for low back pain, leg pain, numbness, JOABPEQ social life disturbance score, SF-36 physical function score, and HADS anxiety score (p < 0.05). Satisfaction 2 correlated negatively with age at surgery, VAS of leg pain, PCS magnification score, and BS-POP score (p < 0.05). Multiple regression analysis showed significant associations between satisfaction 1 and SF-36 physical function and HADS anxiety scores, and between satisfaction 2 and PCS magnification score (p < 0.05). STATISTICAL ANALYSIS: The preoperative factors independently associated with surgical satisfaction were analyzed utilizing Speaman's rank correlation coefficient and multiple regression analysis. CONCLUSION: Physical function and anxiety were identified as preoperative factors that affected patient satisfaction with surgery. Preoperative assessment of psychological factors and interventions for anxiety may help improve patient satisfaction after surgery for LSS.

Physical performance decreases in the early stage of cervical myelopathy before the myelopathic signs appear: the Wakayama Spine Study.

PURPOSE: We previously revealed a prevalence rate of 24.4% for cervical cord compression (CCC) in a population-based magnetic resonance imaging study. This study aimed to investigate the occurrence of cervical myelopathy (CM) among CCC cases and to reveal the predictors for CM. METHODS: This study is a part of "The Wakayama Spine Study," a large-scale population-based MRI cohort study. At baseline, 238 patients were diagnosed with CCC. We followed 238 patients who had CCC for more than 4 years, of which 158 (mean age, 68.9 years) participated in the second survey (follow-up rate, 66.3%). In the second survey, de novo CM was defined clinically as the presence of myelopathic signs (e.g., Hoffmann reflex, hyperreflexia of the patellar tendon, and Babinski reflex). Physical performance on 10-s grip and release test (GRT), grip strength, 6-m walking time at a usual and a maximal pace, step length at a usual and a maximal pace, chair stand time (CST), and one-leg standing (OLS) time was measured. RESULTS: Among the 158 participants, nine (mean age, 68.8 years; incidence rate, 6.3%) were newly diagnosed with CM in the second survey. CST, 6-m walking time at a usual and a maximal pace, and step length at a maximal pace had already decreased in the de novo CM (+) participants at baseline compared to baseline findings of de novo (-) CM participants, but not the grip strength, OLS, or GRT. CONCLUSIONS: We clarified the incidence rate of CM in CCC patients and the predictors of de novo CM. These slides can be retrieved under Electronic Supplementary Material.

Factory and construction work is associated with an increased risk of severe lumbar spinal stenosis on MRI: A case control analysis within the wakayama spine study.

BACKGROUND: To explore the association of MRI-diagnosed severe lumbar spinal stenosis with occupation. METHODS: Occupational data were collected by questionnaire and all participants underwent spine MRI scans using the same protocol. Central lumbar spinal stenosis (LSS) was graded qualitatively. Those with severe LSS (>two-thirds narrowing) were compared with the controls with lesser degrees of stenosis or no stenosis. RESULTS: Data were available for 722 subjects, mean age 70.1 years. 239 (33%) cases with severe LSS were identified. Factory/construction workers had an almost four-fold increased risk of severe LSS after adjustment for age, sex, smoking, and walking speed amongst those aged <75 years (OR 3.97, 95%CI 1.46-10.85). Severe LSS was also associated with squatting ≥1 h/day (OR 1.76, 95%CI 1.01-3.07) but this association became non-significant after adjustment. CONCLUSION: Further research is needed but this study adds more evidence that occupational factors are associated with an increased risk and/or severity of degenerative disease of the lumbar spine.

Is radiographic lumbar spondylolisthesis associated with occupational exposures? Findings from a nested case control study within the Wakayama spine study.

BACKGROUND: To explore the relationship between radiographic spondylolisthesis and occupational factors in a case-control study nested within the Wakayama Spine Study (WSS). METHODS: The WSS is a cross-sectional observational study amongst Japanese adults. All participants completed a lifetime occupational history and underwent X-rays of the lumbar spine (L1-S1) according to a pre-defined protocol. One trained surgeon graded the presence of a spondylolisthesis based upon ≥5% anterior or posterior slip at one or more levels. Cases, with lumbar spondylolisthesis, were compared with controls without, for their principal occupation and occupational exposures. RESULTS: In total, data were available for 722 adults (245 men and 477 women), mean age 70.1 (range 53-93) years. According to the pre-defined radiographic criteria, 117 were defined with spondylolisthesis (cases), leaving 605 controls. Cases were not significantly different from controls for age, gender, BMI, smoking or alcohol intake. However, cases were more than twice as likely to report occupational driving ≥4 h/day (OR 2.39, 95% CI 1.08-5.27) after adjustment for age, gender and BMI. Additionally, after stratification by age using 75 years as a cut-point, cases were more than 3-fold more likely to report having worked in the agricultural/ fishing industries (OR 3.47, 95% CI 1.29-9.29) among those aged < 75 years. A reduced risk of being a case was associated with climbing slopes/steps and walking. CONCLUSIONS: A history of occupational driving and working in the agricultural/fishing industry were associated with radiographic spondylolisthesis in this cross-sectional population study. This finding requires further evaluation in longitudinal studies.

A comparative study of 2-year follow-up outcomes in lumbar spinal stenosis patients treated with physical therapy alone and those with surgical intervention after less successful physical therapy.

BACKGROUND: The efficacy of physical therapy for patients with lumbar spinal stenosis (LSS) has been reported only for the short term, and few reports have compared outcomes of surgical treatment with nonsurgical treatment after physical therapy. The purpose of this study was to assess 2-year outcomes of LSS patients treated with surgery or under follow-up observation after physical therapy for 6 weeks. METHODS: Patients presenting with neurogenic claudication, radiologically-confirmed central LSS affecting both legs and refractory symptoms to pharmacotherapy of more than 3 months were enrolled. Patients were treated with manual therapy, stretching and strengthening exercises, and body weight-supported treadmill walking once a week for 6 weeks. Clinical outcomes were measured using the Zurich Claudication Questionnaire (ZCQ), visual analog scale of low back pain, leg pain, and numbness, the Japanese Orthopedic Association Back Pain Evaluation Questionnaire and the SF-36. Two years after physical therapy, patients were classified into the observation group (Group I) or the surgery group (Group II), whose patients failed to respond to physical therapy and wanted to undergo surgery. RESULTS: Thirty-eight patients were enrolled; 28 had complete data at 2 years: 21 and 7 in Groups I and II, respectively. Group II had a higher body mass index (BMI) than Group I. There were no significant differences in clinical outcomes at baseline. Six weeks after physical therapy, Group I had significantly better outcomes for symptom severity and physical function on the ZCQ subscales, physical functioning and bodily pain on the SF-36 subscales. These outcomes in Group I were maintained or improved and did not differ significantly between groups at 2-years. However, the physical function on the ZCQ subscales was improved in Group II more than those in Group I (mean difference -0.6; 95% CI: -1.2 to -0.03, P < 0.05) at 2 years. CONCLUSIONS: At 2 years, the outcomes except for the change in physical function score in the ZCQ subscale did not differ significantly between patients who had undergone surgery and those who avoided surgery.