Instrumentation failure following pediatric spine deformity growth-sparing surgery using traditional growing rods or vertical expandable prosthetic titanium ribs.

BACKGROUND: Instrumentation failure (IF) is a major complication associated with growth-sparing surgery for pediatric spinal deformities; however, studies focusing on IF following each surgical procedure are lacking. We aimed to evaluate the incidence, timing, and rates of unplanned return to the operating room (UPROR) associated with IF following each surgical procedure in growth-sparing surgeries using traditional growing rods (TGRs) and vertical expandable prosthetic titanium ribs (VEPTRs). METHODS: We reviewed 1,139 surgical procedures documented in a Japanese multicenter database from 2015 to 2017. Of these, 544 TGR and 455 VEPTR procedures were included for evaluation on a per-surgery basis. IF was defined as the occurrence of an implant-related complication requiring revision surgery. RESULTS: The surgery-based incidences of IF requiring revision surgery in the TGR and VEPTR groups were 4.3% and 4.0%, respectively, with no significant intergroup difference. Remarkably, there was a negative correlation between IF incidence per surgical procedure and the number of lengthening surgeries in both groups. In addition, rod breakage in the TGR group and anchor-related complications in the VEPTR group tended to occur relatively early in the treatment course. The surgery-based rates of UPROR due to IF in the TGR and VEPTR groups were 2.0% and 1.5%, respectively, showing no statistically significant difference. CONCLUSIONS: We found that IF, such as anchor related-complications and rod breakage, occurs more frequently earlier in the course of lengthening surgeries. This finding may help in patient counseling and highlights the importance of close postoperative follow-up to detect IF and improve outcomes.

Relationship between lumbosacral transitional vertebra and postoperative outcomes of patients with Lenke 5C adolescent idiopathic scoliosis: a minimum 5-year follow-up study.

PURPOSE: To assess the incidence of lumbosacral transitional vertebra (LSTV) in Lenke 5C adolescent idiopathic scoliosis (AIS) and evaluate the relationship between postoperative outcomes and LSTV when the lowest instrumented vertebra (LIV) is fixed at L3. METHODS: The study included 61 patients with Lenke 5C AIS who underwent fusion surgery of L3 as the LIV who were followed-up for a minimum of 5 years. Patients were divided into two groups: LSTV + and LSTV-. Demographic, surgical, and radiographic data, including L4 tilt and thoracolumbar/lumbar (TL/L) Cobb angle, were obtained and analyzed. RESULTS: LSTV was observed in 15 patients (24.5%). The L4 tilt was not significantly different between the two groups preoperatively (P = 0.54); however, it was significantly greater in the LSTV group postoperatively (2 weeks: LSTV + = 11.7 ± 3.1, LSTV - = 8.8 ± 3.2, P = 0.013; 2 years: LSTV + = 11.5 ± 3.5, LSTV - = 7.9 ± 4.1, P = 0.006; 5 years: LSTV + = 9.8 ± 3.1, LSTV - = 7.3 ± 4.5, P= 0.042). The postoperative TL/L curve was greater in the LSTV + group, with significant differences at 2 weeks and 2 years postoperatively (preoperative: LSTV + = 53.5 ± 11.2, LSTV - = 51.7 ± 10.3,P = 0.675; 2 weeks: LSTV + = 16.1 ± 5.0, LSTV- = 12.2 ± 6.6, P = 0.027; 2 years: LSTV + = 21.7 ± 5.9, LSTV - = 17.6 ± 5.9, P = 0.035; 5 years: LSTV + = 18.7 ± 5.8, LSTV - = 17.0 ± 6.1, P = 0.205). CONCLUSION: The prevalence of LSTV in Lenke 5C AIS patients was 24.5%. Lenke 5C AIS patients with LSTV with the LIV at L3 had a significantly greater postoperative L4 tilt than those without LSTV and retained the TL/L curve.

Nonanesthetized Alternatively Repetitive Cast and Brace Treatment for Early-onset Scoliosis.

BACKGROUND: Use of cast is a standard treatment (Tx) choice for early-onset scoliosis. Recently, toxicity from repetitive use of general anesthesia has received attention by the Food and Drug Administration (FDA). We introduce a nonanesthetized cast Tx protocol called alternatively-repetitive-cast-and-brace (ARCB) that we have used since 1995 and have conducted an extensive follow-up on these patients to verify the efficacy of this protocol. STUDY DESIGN: This is a retrospective cohort study. METHODS: Of a consecutive series of 155 patients who have undergone cast Tx at a single institution, 98 patients (male: 36, female: 62) have been identified under the following criteria: (1) Initial age before ARCB of ≤6; (2) Follow-up period of ≥2 years; (3) Initial scoliosis ≥35 degrees. Patients consisted of the following: congenital/structural: 45, idiopathic: 23, neuromuscular: 6, syndromic: 24. Precast, postfinal cast, minimum in-cast Cobb, as well as thoracic and T1-S1 heights were measured. Fifty-six of these patients had available pulse oximetry on days before and after initial cast, and these were also evaluated to assess cardiopulmonary effects that the cast have on the patients. RESULTS: Patients were casted 6.6 times, with a mean initial Cobb of 56.5 degrees and a final follow-up Cobb of 57.1 degrees. Follow-up period was 5.0 years. Mean curve progression per follow-up period was 0.5 degrees/y. Minimum in-cast Cobb was 25.6 degrees. Initially patients had a thoracic and T1-S1 height of 12.6 and 22.5 cm, respectively. At final cast, these were 15.3 and 27.2 cm, respectively. Of these patients, 39 had progression >1 degree/y, of which 83.1% had resulted in surgical correction, while this was true for only 37.3% of those that did not show such progression. Idiopathic patients had the greatest correction rate by cast (69%) and had shown an overall progression rate of -2.3 degrees/y. Pulse-oximetry results were not significant amongst patients before and after cast placement. CONCLUSIONS: ARCB is a versatile and practical Tx choice. It is an effective delaying method in sparing time until surgery with no apparent cardiopulmonary compromise. Curve control was most effective in Idiopathic patients while some curve control was achieved in other etiologies which may have spared time until their eventual surgery. SIGNIFICANCE: Cast Tx without the need of general anesthesia is an increasingly important topic since anesthesia toxicity from its repetitive use has become apparent. This study exemplifies safe and efficacious use of such cast with effective suppression on cast progression in different etiologies at various degrees.

Long-term Surgical Outcomes After Early Definitive Spinal Fusion for Early-onset Scoliosis With Neurofibromatosis Type 1 at Mean Follow-up of 14 Years.

BACKGROUND: Several authors mentioned surgical outcome for scoliosis associated with neurofibromatosis type 1 (NF-1). However, no studies have summarized long-term surgical outcomes after surgical treatment of early-onset scoliosis (EOS) with NF-1. The purpose of this study is to evaluate the long-term surgical outcome after early definitive spinal fusion for EOS in NF-1 patients. METHODS: We performed a retrospective review on a cohort of 11 patients diagnosed with EOS associated with NF-1 between 1990 and 2009 in our hospital. The study included 7 male and 4 female NF-1 patients with a mean age at fusion surgery of 8 years 4 months who underwent early definitive spinal fusion for EOS. We reviewed radiographs, computed tomography and magnetic resonance images for each patient. The data collected included type of NF-1, Cobb angles, kyphotic angle, spinal length (T1-S1), and pulmonary function. We also evaluated progression of the dystrophic change through radiographs and computed tomography during the follow-up period. RESULTS: The mean follow-up duration was 14 years (5 y 10 mo to 25 y). All patients underwent anterior and posterior fusion surgeries in either 1 or 2 stages. Seven cases had subtotal tumor resection from the concave side followed by rib strut grafting. The mean preoperative Cobb angle of the primary curve was corrected from 71.2 to 24.1 degrees and was maintained at the final follow-up at 23.5 degrees. Mean values for preoperative and final follow-up T1-S1 heights were 30.7 and 36.2 cm, respectively. Mean values for preoperative and final follow-up % forced vital capacity (the present/the predicted) were 75.0% and 74.4%, respectively. The dystrophic change progressed in all cases during the long-term follow-up. CONCLUSIONS: Our goals for NF-1 scoliosis are to obtain deformity correction, to achieve stable instrumentation by using longer fusion levels and to attain a solid fusion mass that can tolerate continual erosion during the long-term follow-up. We achieve this by using a circumferential approach for EOS associated with NF-1. LEVEL OF EVIDENCE: Level IV-case series.

Comparison of Early Definitive Fusion and Traditional Growing Rods in Early-onset Dystrophic Scoliosis in Neurofibromatosis Type 1: A Preliminary Report.

BACKGROUND: Early definitive spinal fusion (EF) has been widely recommended to avoid spinal deformity progression for early-onset scoliosis (EOS) with neurofibromatosis type 1 (NF-1). In contrast, growing rod (GR) procedure has recently been recommended for EOS associated with the dystrophic type NF-1. However, no studies have compared the surgical outcomes between EF and GR procedure for EOS with NF-1. The purpose of this study was to compare the surgical outcomes of EF versus GR for early onset and dystrophic scoliosis with NF-1. METHODS: This was a retrospective multicenter study; 26 EOS patients with dystrophic type of NF-1 who underwent EF (16 patients) or GR (10 patients) were investigated. We compared age at first surgery, fused levels, total number of surgeries, coronal major curve, complication rates, spinal height (T1-T12 and T1-S1 length), and forced vital capacity between the 2 groups. RESULTS: The mean age at first surgery was 7.3 years in the EF and 5.8 years in the GR (P<0.05). The mean follow-up period was 12.8 and 10.5 years, respectively. The 2 groups did not show significant differences in preoperative major Cobb angle (75.1 vs. 83.1 degrees), complication rate (53% vs. 60%), and increase rate of T1-T12 (20.0% vs. 30.4%). However, significant differences (P<0.05) were recognized in fusion segments (13.9 vs. 15.8), total numbers of surgery (2.6 vs. 10.1), correction rate of major curve (59.0% vs. 40.6%), increase rate of T1-S1 (19.0% vs. 33.9%), body height at final follow-up (151 vs. 142 cm), and forced vital capacity at final follow-up (2.23 vs. 1.46 L). CONCLUSIONS: Early fusion is still a viable option for progressive EOS with dystrophic type of NF-1 even in the growth-friendly era. Surgeons should consider the best procedure for each patient taking into account the severity of dystrophic change when treating EOS with NF-1. LEVEL OF EVIDENCE: Level IV.

Evaluation of thoracic factors after scoliosis surgery in patients with both scoliosis and pectus excavatum.

PURPOSE: Pectus excavatum can negatively impact cardiac function during scoliosis surgery. Several authors reported severe hypotension associated with the prone position during scoliosis surgery in children that had both scoliosis and pectus excavatum. However, we could find no studies that evaluated the change in the thoracic factors, such as sternal tilt angle and Haller index after scoliosis surgery in patients with both scoliosis and pectus excavatum. The purpose of this study is to evaluate the change in thoracic factors after surgical treatment for scoliosis associated with pectus excavatum. METHODS: We performed a retrospective review on 20 patients (10 males and 10 females) who underwent surgical treatment for scoliosis associated with pectus excavatum from August 2004 to April 2014 in our hospital. We investigated the scoliosis diagnosis, preoperative and postoperative Cobb and thoracic kyphosis (TK) angles, the change in TK after surgery and thoracic factors, including the AP and transverse diameters of the chest, the sternal tilt angle, and Haller index. RESULTS: Patient mean age was 13.2 years old (4-27 years old) at surgery. Types of scoliosis were idiopathic in 8 patients, syndromic in 10, and neuromuscular in 2. The mean Cobb angles were 72.1° preoperatively and 19.0° postoperatively. Curve locations were thoracic in 13 patients, thoracolumbar in 4, and lumbar in 3. Surgical treatment of pectus excavatum was performed in 9 patients (45 %) before scoliosis treatment. Mean sternal tilt angles were 11.5° preoperatively and 11.1° postoperatively. Mean Haller indices were 4.8 preoperatively and 5.3 postoperatively. This was especially true for syndromic or neuromuscular scoliosis and thoracolumbar/lumbar curve type patients in which scoliosis surgery tended to worsen the Haller index. CONCLUSION: The Haller index increased postoperatively in 11 of 20 patients, which means sternal depression deteriorated after scoliosis surgery in about 50 % of patients. We suggest that surgeons fully assess the thoracic factors in patients with scoliosis and pectus excavatum prior to performing scoliosis surgery and carefully monitor their patient's general condition during surgery.

Three-Dimensional Analysis of Hemimetameric Segmental Shift in Congenital Scoliosis.

STUDY DESIGN: This is a retrospective cohort study. BACKGROUND: Hemimetameric segmental shift (HMMS) is defined as a hemivertebral deformation in which 2 or more hemivertebrae exist on both sides of the spine and are separated by at least 1 normal vertebra. Reports of HMMS are rare and based on simple anterior x-ray images. No reports have used 3-dimensional computed tomography (3D-CT) to analyze both the anterior and posterior elements. The objective of this study was to analyze the morphology and clinical features of HMMS 3 dimensionally. METHODS: HMMS was confirmed in 32 (6.6%, 16 males and 16 females) of 483 patients diagnosed with congenital scoliosis at the study institution between 1998 and 2013. The average age at the first visit was 6 years and 3 months. 3D-CT imaging was performed for 30 patients older than 2 years (average age: 9 y and 8 mo) and used to classify cases according to posterior elements. RESULTS: With regard to the number of hemivertebrae present, 21 patients had 2 hemivertebrae, 7 patients had 3 hemivertebrae, and 2 patients had 4 hemivertebrae. Patients with 2 hemivertebrae predominantly had hemivertebrae in the thoracolumbar spine. Patients were classified into 2 categories: malformation existing at an equal level in anterior and posterior sides (unison HMMS) and malformation existing at nonequal levels (discordant HMMS). Nine patients had unison HMMS and all of them had 2 hemivertebrae (average: 4.6 vertebrae). Twenty-one patients had discordant HMMS, with 12 having 2 hemivertebrae, 7 having 3 hemivertebrae, and 2 having 4 hemivertebrae. CONCLUSIONS: Through 3D-CT analysis, HMMS was categorized as unison or discordant. Discordant HMMS was observed in 21 of 30 (70%) patients and in all patients with >3 hemivertebrae. Diagnosing HMMS, whether unison or discordant, is clinically important and should be done with careful analysis of bone models and/or radiologic images to determine the correct spinal levels. LEVEL OF EVIDENCE: Level IV-diagnostic study.

Clinical Impact of Corrective Cast Treatment for Early Onset Scoliosis: Is It a Worthwhile Treatment Option to Suppress Scoliosis Progression Before Surgical Intervention?

BACKGROUND: Although corrective cast (CC) has been back in use for the treatment of early onset scoliosis (EOS), no studies have reported how clinically meaningful CC was in comparison with brace-only treatment (BT) in EOS. The aim of this study was to investigate the effect of CC treatment in terms of suppression of scoliosis progression before surgery. METHODS: This study was designed to conduct a comparison of patients treated at 2 spine institutions differing in treating methods (one: mainly CC with brace, the other: BT). Applying casts were performed without general anesthesia and repeatedly with the interval of 2 to 6 months combined with corrective brace application called alternatively repetitive cast and brace treatment (ARCBT). In total, 58 patients met the following criteria: (1) age at the first visit ≤6 years, (2) scoliosis ≥40 degrees, (3) conservative treatment≥2 years. Patients with congenital scoliosis were excluded in this study. In total, 58 patients were divided into 2 groups; cast/brace group (C/B-G) and BT group (B-G). RESULTS: There were no significant differences of diagnosis (P=0.2773), sex (P=0.0670), age at the first visit (P=0.1457), scoliosis magnitude (P=0.1980), and duration for conservative treatment (P=0.2578) between 2 groups. Most of the patients who were treated with ARCBT, were switched to BT due to lower compliance for CC after the age of around 7 years. The progression of scoliosis during ARCBT and BT were 4.4 and 5.8 degree/y, respectively. Those during ARCBT in C/B-G was 2.8 degree/y comparing with 8.4 degree/y after switch to BT after 7 years of age. There was a significant difference between scoliosis progression during ARCBT in C/B-G and that of B-G (P=0.0086). CONCLUSIONS: This study showed that ARCBT had a significant impact on suppression of scoliosis progression compared with BT in EOS. However, the termination of cast application and the switch to BT may be still a clinical question considering the time to surgical intervention. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Reliability analysis of Cobb angle measurements of congenital scoliosis using X-ray and 3D-CT images.

PURPOSE: Therapeutic decisions for congenital scoliosis rely on Cobb angle measurements on consecutive radiographs. There have been no studies documenting the variability of measuring the Cobb angle using 3D-CT images in children with congenital scoliosis. The purpose of this study was to compare the reliability and measurement errors using X-ray images and those utilizing 3D-CT images. MATERIALS AND METHODS: The X-ray and 3D-CT images of 20 patients diagnosed with congenital scoliosis were used to assess the reliability of the digital 3D-CT images for the measurement of the Cobb angle. Thirteen observers performed the measurements, and each image was analyzed by each observer twice with a minimum interval of 1 week between measurements. The analysis of intraobserver variation was expressed as the mean absolute difference (MAD) and standard deviation (SD) between measurements and the intraclass correlation coefficient (IaCC) of the measurements. In addition, the interobserver variation was expressed as the MAD and interclass correlation coefficient (IeCC). RESULTS: The average MAD and SD was 4.5° and 3.2° by the X-ray method and 3.7° and 2.6° by the 3D-CT method. The intraobserver and interobserver intraclass ICCs were excellent in both methods (X-ray: IaCC 0.835-0.994 IeCC 0.847, 3D-CT: IaCC 0.819-0.996 IeCC 0.893). There was no significant MAD difference between X-ray and 3D-CT images in measuring each type of congenital scoliosis by each observer. CONCLUSIONS: Results of Cobb angle measurements in patients with congenital scoliosis using X-ray images in the frontal plane could be reproduced with almost the same measurement variance (3°-4° measurement error) using 3D-CT images. This suggests that X-ray images are clinically useful for assessing any type of congenital scoliosis about measuring the Cobb angle alone. However, since 3D-CT can provide more detailed images of the anterior and posterior components of malformed vertebrae, the volume of information that can be obtained by evaluating them has contributed greatly to the development of strategies for the surgical treatment of congenital scoliosis.

Influence of spinal imbalance on knee osteoarthritis in community-living elderly adults.

Previous studies evaluated various risk factors for knee OA; however, no study has examined the association between spinal factors, such as total spinal alignment and spinal range of motion (ROM), with knee OA. The purpose of this study was to examine the influence of spinal factors including total spinal alignment and spinal ROM on knee OA in community-living elderly subjects. A total of 170 subjects ≥60 years old (mean age 69.4 years, 70 males and 100 females) enrolled in the study (Yakumo study) and underwent a basic health checkup. We evaluated A-P knee radiographs, sagittal parameters (thoracic kyphosis angle, lumbar lordosis angle, and spinal inclination angle) and spinal mobility (thoracic spinal ROM, lumbar spinal ROM and total spinal ROM) as determined with SpinalMouse(®). The radiological assessment of knee OA was based on the Kellgren and Lawrence classification, and the knee flexion angle was measured while the subject was standing. Spinal inclination angle and thoracic spinal ROM correlated significantly with knee OA on univariate analyses. Multivariate logistic regression analysis indicated that an increase in spinal inclination angle (OR 1.073, p<0.05) was significantly associated with knee OA. Spinal inclination angle had significant positive correlation with knee flexion angle (r=0.286, p<0.001). The spinal inclination angle is the most important factor associated with knee OA.

Surgically treated cases of lumbar spondylolysis and isthmic spondylolisthesis: a multicenter study.

STUDY DESIGN: Prospective database study. OBJECTIVES: To grasp the characteristics of surgically treated cases with lumbar spondylolysis or isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: A detailed analysis of surgically treated cases with spondylolysis or isthmic spondylolisthesis has never been reported. An epidemiological study in Japan conducted on 2000 subjects found the incidence of lumbar spondylolysis in the Japanese general population (population-based study) to be 5.9% (males: 7.9%, females: 3.9%). Among 124 vertebrae with spondylolysis, there were 0.8% L2 lesions, 3.2% L3 lesions, 5.6% L4 lesions, and 90.3% L5 lesions, including 5 cases (4.3%) with multiple-level lesions. METHODS: We have been registering surgically treated spine cases in our database since 2000. From this database, we prospectively collected cases with lumbar spondylolysis or isthmic spondylolisthesis that were treated surgically between January 2000 and December 2009. We determined the age at surgery, sex, and vertebral level of spondylolysis. RESULTS: Of the 564 spondylolysis patients treated surgically, 66.8% were male and 33.2% were female. The mean age at surgery was 52.5 years (range, 13-84 y). There were 585 vertebrae with spondylolysis including 21 cases (3.7%) with multiple-level lesions. L5 spondylolysis affected 432 vertebrae and was the most common location (73.8%), followed by 125 L4 lesions (21.4%), 24 L3 lesions (4.1%), and 2 L2 lesions (0.7%). CONCLUSIONS: The percentage of L4 lesions in our study was significantly higher and of L5 lesions was significantly lower than those lesions' percentages in the population-based study. L4 spondylolysis may be more unstable or cause clinical symptoms more frequently leading to more surgical intervention. The percentage of multiple-level spondylolysis was similar between the 2 studies, suggesting these patients respond relatively well to conservative treatment. The male/female ratio was 2:1 in both studies, indicating that males and females require surgery at a similar frequency.

Appropriate timing of surgical intervention for the proximal type of cervical spondylotic amyotrophy.

PURPOSE: The purposes of this study were to evaluate the clinical outcome after surgical treatment of patients with the proximal type of cervical spondylotic amyotrophy (CSA) and to explore the appropriate timing for surgical intervention. MATERIALS AND METHODS: A retrospective review was performed on a consecutive cohort of 41 patients who underwent surgical treatment for the proximal type of CSA between 1995 and 2011 at the Nagoya Spine Group Hospitals. We collected information regarding age, type of muscle atrophy, preoperative and final manual muscle test, duration of symptoms, high-intensity areas on T2-weighted MRI images, low-intensity areas on T1-weighted MRI images, levels of spinal canal stenosis, the compression lesion site, cervical kyphosis and surgical procedures (laminoplasty, anterior spinal fusion and posterior spinal fusion). Univariate analyses and multivariate logistic regression analysis were performed to identify correlates of a poor outcome. To explore the appropriate timing for performing surgery, we analyzed the data using receiver operating characteristic (ROC) analysis. RESULTS: The duration of CSA symptoms was 11.6 months on average. The surgical results were excellent for 25 patients, good for six, fair for nine and poor for one. On multivariate logistic regression analysis, the duration of symptoms was statistically associated with a poor surgical outcome (OR 1.393, p = 0.011). ROC analysis demonstrated that 4.3 months from the onset of CSA symptoms was the appropriate time to undergo surgery. CONCLUSIONS: Our results indicate that we should recommend surgical intervention to patients with the proximal type of CSA within about 4 months after the onset of symptoms if conservative treatment has not been successful.

Chronic spontaneous lumbar epidural hematoma simulating extradural spinal tumor: a case report.

Spinal epidural hematoma (SEH) is an uncommon disorder, and chronic SEHs are rarer than acute SEHs. However, there is few reported involving the bone change of the vertebral body in chronic SEHs. We present a case report of lumbar epidural hematoma that required differentiation from extramedullary spinal tumors by a long process because the CT scan revealed scalloping of the vertebral body and review the relevant literature. A 78-year-old man had experienced a gradual onset of low back pain and excruciating pain in both legs. Lumbar MRI on T1-weighted images revealed a space-occupying lesion with a hyperintense signal relative to the spinal cord with no enhancement on gadolinium adminisration. Meanwhile, T2-weighted images revealed a heterogeneous intensity change, accompanying a central area of hyperintense signals with a hypointense peripheral border at the L4 vertebra. Moreover, the CT scan demonstrated scalloping of the posterior wall of the L4 vertebral body which is generally suspected as the CT finding of spainal tumor. During the epidural space exploration, we found a dark red-colored mass surrounded by a capsular layer, which was fibrous and adhered to the flavum and dura mater. Microscopic histological examination of the resected mass revealed a mixture of the relatively new hematoma and the hematoma that was moving into the connective tissue. Accordingly, the hematoma was diagnosed as chronic SEH. The particular MRI findings of chronic SEHs are helpful for making accurate preoperative diagnoses of this pathology.

Differentiation of spinal schwannomas and myxopapillary ependymomas: MR imaging and pathologic features.

STUDY DESIGN: Retrospective clinical study. OBJECTIVE: The objective of this study is to evaluate magnetic resonance imaging and pathologic features of spinal schwannomas (SCHs) and myxopapillary ependymomas (MPEs) with focus on differentiating 2 disease entities. SUMMARY OF BACKGROUND DATA: Few studies have reported on the differentiation of SCHs and MPEs. METHODS: Fifty-three patients were retrospectively reviewed with histologically confirmed spinal SCHs (41 patients) or MPEs (12 patients) of the cauda equina and/or conus medullaris. We evaluated neurological deterioration after surgery in association with the intraoperative findings of the tumor, as well as with the preoperative magnetic resonance images and postoperative histologic findings. RESULTS: Patients in the SCH group had a greater mean age at surgery and a greater mean disease duration. In the SCH group, all 24 tumors that were homogeneously hyperintense on the T2-weighted (T2W) images showed rim enhancement on the postcontrast T1-weighted (T1W) images. Moreover, all 14 of the SCHs with homogeneous enhancement on the postcontrast T1W images were isointense on the T2W images. However, in the MPE group, all 8 of the tumors that were homogeneously hyperintense on T2W images showed homogeneous enhancement on their postcontrast T1W images. CONCLUSIONS: It is very important to differentiate SCHs and MPEs before surgery, because there are reported cases of dissemination of MPEs through cerebrospinal fluid throughout the neuraxis; the tumor must be removed en block to prevent this. Although MPEs and SCHs may have similar imaging characteristics, detailed examination of the magnetic resonance T2W image and postcontrast T1W image facilitates their differentiation.

Waist circumference is associated with locomotive syndrome in elderly females.

BACKGROUND: Central obesity has been proved to be a strong risk factor for numerous health-related problems as well as mortality. However, there have been no studies on the relationship between central obesity and locomotive syndrome (LS). The present study investigated the influence of central obesity on LS. METHODS: A total of 217 females between the ages of 60 and 79 years (mean 68.2 ± 5.0 years) who completed the questionnaires, physical examination and physical performance tests in the Yakumo study in 2011-2012 were enrolled in this study. Participants were assessed according to the 25-Question Geriatric Locomotive Function Scale (GLFS-25), visual analog scale (VAS) for lower back pain (LBP) and knee pain, and the Roland Morris Disability Questionnaire (RDQ). LS was defined as having a score of >16 points on the GLFS-25. Height, weight, waist circumference (WC), hip circumference, % body fat and bone mineral density were measured. Body mass index and waist-to-hip ratio were calculated. The timed up-and-go test, one-leg standing time with eyes open, 10-m gait time and maximum stride were assessed. Back muscle strength and grip strength were measured. The relationships between obesity-related parameters and GLFS-25, RDQ, VAS and physical performance tests were analyzed. RESULTS: The GLFS-25, LBP and knee pain showed significant correlation with most of obesity-related parameters. Among obesity-related parameters, WC was most strongly related to the GLFS-25, LBP and knee pain. When participants were stratified by WC, larger WC was significantly associated with a higher GLFS-25 score, higher prevalence of LS and higher VAS for LBP and knee pain as well as poorer results in some physical performance tests even after adjustment by age. CONCLUSIONS: The present study revealed that central obesity is significantly associated with LS, and WC can be a useful parameter to assess the risk of LS in elderly women.

Acute pancreatitis after spine surgery: a case report and review of literature.

Although acute postoperative pancreatitis is a relatively frequent complication after open biliary tract surgery and gastric surgery, acute pancreatitis after spine surgery is a rare complication. We report the first case of acute pancreatitis after posterior lumbar interbody fusion (PLIF) for spondylolisthesis that resolved with conservative treatment. A 53-year-old female patient received a PLIF from L3 to L5. The patient presented with persistent mild abdominal pain, nausea and vomiting several hours after the surgery. An abdominal CT revealed swelling of the head of the pancreas and free fluid around the pancreas. A gastroenterologist diagnosed acute pancreatitis and prescribed nafamostat mesilate, antibiotics and intravenous fluid therapy. The patient recovered gradually, and clinical symptoms disappeared. At 6 months after the operation, she had experienced no recurrence of abdominal symptoms, and solid spinal fusion was achieved. In previous studies, acute pancreatitis was reported as a complication after spine surgery for various spine diseases such as scoliosis and lumbar disorders. The procedures performed included anterior/posterior scoliosis surgery and anterior/posterior lumbar fusion surgery. We must consider the possibility of acute pancreatitis when unusual abdominal symptoms with elevated serum amylase levels occur after spine surgery. Prompt diagnosis and supportive therapy are essential to minimize morbidity and mortality.

Atlantoaxial rotatory fixation in a child after bilateral otoplastic surgery.

Atlantoaxial rotatory fixation (AARF), which is a dislocation or subluxation of the atlantoaxial joint, is a well-recognized condition in children. We present a case of AARF after otoplastic surgery for bilateral cryptotia performed by plastic surgeons. The pediatric patient presented with neck pain and torticollis after the surgery, and an orthopedic surgeon diagnosed AARF. The patient was treated successfully with conservative treatment incorporating mild manual manipulation, neck traction, and a collar for 1.5 months. Physicians should consider the possibility of AARF when a patient presents with neck pain and torticollis after otoplastic surgery; diagnosis and treatment should be started immediately.

Rod fracture after multiple-rod technique for adult spinal deformity: a case report.

Here we report the case of a 71-year-old woman who complained of lower back and left leg pain due to rod fracture following instrumented fusion using the lateral lumbar interbody fusion and multi-rod technique to treat adult spinal deformity. Radiographic images revealed bilateral rod fractures at L4-5 and pseudoarthrosis at L2-5; lower lumbar lordosis was minimal, but upper lumbar hyperlordosis was noted. The patient underwent revision surgery, which included posterior spinal instrument replacement, L3-4 and L4-5 lateral lumbar interbody fusion cage removal, and L4 vertebral body replacement via the anterior approach. This is a rare case of reoperation with the multi-rod technique. Revision surgery should be performed in consideration of the proportion of lumbar lordosis and anterior bony fusion as the posterior component is resected and bony fusion can only be achieved anteriorly.

The correlation between cervical range of motion and misplacement of cervical pedicle screws during cervical posterior spinal fixation surgery using a CT-based navigation system.

PURPOSE: The aim of this study was to analyze the correlation between cervical range of motion and cervical pedicle screw (CPS) misplacement in cervical posterior spinal fusion surgery using a CT-based navigation system. METHODS: A total of 46 consecutive patients with cervical posterior spinal fusion surgery using CPSs were evaluated retrospectively. We analyzed the cervical range of motion (ROM) and the misplacement of CPSs that were placed using either separate or single-time multilevel registration with a CT-based navigation system to determine the optimum registration procedure. The screw-inserted vertebra was indicated as Registered vertebra-Pedicle Screw inserted vertebra (Re-PS) = 0, 1, 2, or 3 depending on its distance (level) from the registered vertebra. Grades 0 (no perforation) and 1 (perforations <2 mm) were categorized as "no misplacement." Grades 2 (perforations ≧ 2 mm but < 4 mm) and 3 (perforations ≧ 4 mm) were categorized as "misplacement." We analyzed the correlations between CPS misplacement and Re-PS, and between CPS misplacement and preoperative cervical ROM. RESULTS: Our analysis included 196 screws in patients having a mean age of 53.2 years (range 5-84 years). Level of insertion relative to registration was Re-PS = 0 in 129 screws, Re-PS = 1 in 53, Re-PS = 2 in 10 and Re-PS = 3 in 4. The misplacement rates were 12.2 % (24 screws) overall, 6.2 % in Re-PS = 0, 22.6 % in Re-PS = 1, 20 % in Re-PS = 2, and 50 % in Re-PS = 3. The rate of CPS misplacement increased significantly with a Re-PS = 1 and a Re-PS = 2 and 3 compared to a Re-PS = 0. There was a significant difference in the cervical ROM in each grade and both misplacement groups: 1.8 in Grade 0, 2.3 in Grade 1, 7.8 in Grade 2, 12.9 in Grade 3, 11 in the misplacement group and 1.9 in the no misplacement group. CONCLUSIONS: The precision of CPS placement in CT-based navigation surgery was evaluated. The misplacement rate in single-time multilevel registration increased to 23.4 % compared to 6.2 % for separate registration. As the distance increased between the registered level and the level of CPS insertion, the preoperative cervical ROM and the rate of CPS misplacement significantly increased. Thus, the rate of misplacement of CPSs is reduced when performing separate registration. Furthermore, when there is greater preoperative cervical ROM, separate registration would likely improve the safety and accuracy of CPS insertion.

The effects of surgery on locomotion in elderly patients with cervical spondylotic myelopathy.

PURPOSE: This study aimed to evaluate the effects of surgery on locomotor ability in patients with cervical spondylotic myelopathy (CSM) and compare the results between elderly and younger patients. METHODS: A total of 369 consecutive patients who underwent expansive laminoplasty for CSM were prospectively analysed. Patients were divided into two age groups of ≥ 75 years (elderly group, 76 patients) and <75 years (younger group, 293 patients). Locomotor ability was estimated using part of the functional independence measure (FIM). The sum of gait and stairs items [functional independence measure (locomotion), FIM-L; possible scores, 2-14] and neurological status were estimated using the Japanese Orthopaedic Association (JOA) score (possible score, 0-17). Pre-operative neurological anamnesis was reviewed, and the surgical results of elderly patients with or without co-existing neurological history were evaluated to determine the origin of locomotor disability. RESULTS: Peri-operative FIM-L and JOA scores were significantly lower in the elderly group than in the younger group, and the opposite was true for improved FIM score. Cerebral infarction and previous lumbar surgery were identified as neurological co-morbidities in the elderly group. However, there was no significant difference in surgical results between elderly patients with and without co-existing neurological disorders. CONCLUSIONS: Decompression surgery can improve locomotor ability and decrease nursing care requirements among elderly patients with CSM. However, other neurological diseases can co-exist in elderly patients, making it difficult to diagnose the origin of locomotor disability. Therefore, detailed peri-operative work-up and timely decompression should be given priority to avoid progression towards fixed locomotor disability.