Patient-specific guide systems decrease the major perforation rate of pedicle screw placement in comparison to the freehand technique for adolescent idiopathic scoliosis.

PURPOSE: This study aimed to compare the accuracy of pedicle screw (PS) placement between a low-profile three-dimensional (3D) printed patient-specific guide system and freehand technique for adolescent idiopathic scoliosis (AIS) surgery. METHODS: Patients with AIS who underwent surgery between 2018 and 2023 at our hospital were included in the study. The 3D-printed patient-specific guide was used since 2021 (guide group). PS perforation was classified using Rao and Neo's classification (grade 0, no violation; grade 1, < 2 mm; grade 2, 2-4 mm; grade 3, > 4 mm). Major perforations were defined as grades 2 or 3. The major perforation rate of PS, operative time, estimated blood loss (EBL), and correction rate were compared between the two groups. RESULTS: A total of 576 PSs were inserted in 32 patients (20 patients in the freehand (FH) group and 12 patients in the guide group). The major perforation rate was significantly lower in the guide group than in the FH group (2.1% vs. 9.1%, p < 0.001). Significantly fewer major perforations were observed in the guide group than in the FH group in the upper thoracic (T2-4) region (3.2% vs. 20%, p < 0.001) and lower thoracic (T10-12) region (0% vs. 13.8%, p = 0.001). The operative time, EBL, and correction rate were equivalent between the two groups. CONCLUSION: The 3D-printed patient-specific guide notably reduced the major perforation rate of PS without increasing EBL and operative time. Our findings indicate that this guide system is reliable and effective for AIS surgery.

Adjacent vertebral Hounsfield unit value of acute osteoporotic vertebral fracture is a risk factor for concomitant domino osteoporotic vertebral fractures.

BACKGROUND: Most patients with acute osteoporotic vertebral fracture (AOVF) are successfully treated conservatively. However, the optimal management method and prognosis for multiple AOVFs are unclear. This study aimed to investigate the prevalence of multiple AOVFs and identify the associated risk factors. METHODS: This study enrolled 134 hospitalized patients (mean age 83 ± 7.6 years, 66% women) with AOVF treated conservatively between 2017 and 2020. The fractures were diagnosed by magnetic resonance imaging (MRI). The AOVFs were divided into two groups; single osteoporotic vertebral fractures (OVF) and domino OVFs (at least two OVFs). The adjacent vertebral Hounsfield unit values (HU) of the OVF and dual x-ray absorptiometry (DXA) of the lumbar spine or hip were used to evaluate the bone mineral density (BMD). Logistic regression analysis was performed to identify the risk factors for domino OVFs. RESULTS: Domino OVFs were noted in 21 (15.7%) of 134 patients. There were 10 cases of adjacent level and 11 cases of remote level. The BMI (18.5 ± 4.2 vs. 21.2 ± 4.6, p = 0.025) and adjacent vertebral HU value of OVF (57.3 ± 17.5 vs. 76.6 ± 24.1, p = 0.008) were significantly lower in the domino OVFs group than in the single OVF group. Logistic regression analysis revealed the adjacent vertebral HU value of the OVF as an independent risk factor for domino OVFs, (odds ratios (OR) 0.96, p = 0.012). The domino OVF group had a significantly higher decline in gait ability (76% vs. 48%, p = 0.017). CONCLUSIONS: The adjacent vertebral HU value of AOVF is a useful tool for evaluating BMD for domino OVFs. The optimal treatment for osteoporosis should be considered to prevent subsequent domino OVFs.

The Relationship between the Hounsfield Units Value of the Upper Instrumented Vertebra and the Severity of Proximal Junctional Fracture after Adult Spinal Deformity Surgery.

Background and Objectives: In this retrospective cohort study, we investigate associations between the Hounsfield units (HU) value of upper instrumented vertebra (UIV) and proximal junctional kyphosis (PJK) after adult spinal deformity (ASD) surgery. Materials and Methods: The cohort consisted of 60 patients (mean age 71.7 years) who underwent long instrumented fusion surgery (≥6 vertebrae) for ASD with at least 1 year of follow-up. The preoperative bone mineral density (BMD) measured on DXA scans, the HU values at UIV and UIV+1, and the radiographic parameters were compared between the PJK and non-PJK groups. The severity of UIV fracture was assessed using a semiquantitative (SQ) grade. Results: PJK occurred in 43% of patients. No significant differences in patient age, sex, BMD, and preoperative radiographic parameters were observed between the PJK and non-PJK groups. The HU values of the UIV (103.4 vs. 149.0, p < 0.001) and UIV+1 (102.0 vs. 145.7, p < 0.001) were significantly lower in the PJK group. The cutoff values of HU at UIV and UIV+1 were 122.8 and 114.9, respectively. Lower HU values at UIV (Grade 1: 134.2, Grade 2: 109.6, Grade 3: 81.1, p < 0.001) and UIV+1 (Grade 1: 131.5, Grade 2: 107.1, Grade 3: 82.1, p < 0.001) were associated with severe SQ grade. Conclusions: Lower HU values at UIV and UIV+1 had a negative impact on signal incidence of PJK and were correlated with the severity of UIV fractures. Preoperative treatment of osteoporosis seems necessary for preoperative UIV HU values less than 120.

Subsequent Domino Osteoporotic Vertebral Fractures Adversely Affect Short-Term Health-Related Quality of Life: A Prospective Multicenter Study.

Background and Objectives: Conservative treatment is the gold standard for acute osteoporotic vertebral fractures (AOVFs). However, the treatment strategy for multiple AOVFs remains unknown. We conducted a prospective study using magnetic resonance imaging (MRI) to investigate how rapidly subsequent osteoporotic vertebral fractures (OVFs) occur as domino OVFs within 3 months. This study aimed to assess the incidence and impact of domino OVFs on quality of life (QOL) following conservative treatment for initial AOVFs. Materials and Methods: A prospective multicenter cohort study was conducted at eight hospitals. The included patients were those with AOVFs occurring within 3 weeks, aged >60 years, and diagnosed using MRI. All patients were treated conservatively and underwent MRI after 3 months. Subsequent domino OVFs were defined as newly occurring OVFs within 3 months. Patient characteristics, types of conservative treatment, and patient-reported outcomes, including a visual analogue scale (VAS), the Oswestry disability index (ODI), and the Japanese Orthopaedic Association back pain evaluation questionnaire (JOABPEQ), were evaluated and compared between the domino OVF and non-domino OVF groups. Results: A total of 227 patients were analyzed. The mean age was 80.1 ± 7.3 years and 78% were female. Subsequent domino OVFs were observed in 31 (13.6%) patients within 3 months. An increasing number of prevalent OVFs were significantly associated with domino OVFs (p = 0.01). No significant differences in bone mineral density, type of brace, and anti-osteoporosis medications were found between the two groups. The JOABPEQ (excluding social function), ODI, and VAS were significantly improved after 3 months. Patients with domino OVFs at 3 months had poorer JOABPEQ social life function, ODI, and VAS than those with non-domino OVFs. Conclusions: In this study, the incidence of domino OVFs was 13.6% within 3 months. Domino OVFs had a negative impact on QOL at 3 months and were associated with prevalent OVFs.

The Impact of Controlling Nutritional Status (CONUT) score on functional prognosis in hospitalized elderly patients with acute osteoporotic vertebral fractures.

BACKGROUND: Nutritional status, which is associated with osteoporosis and muscle weakness is considered an important factor in the management of acute osteoporotic vertebral fracture (AOVF). However, few reports have investigated the nutritional status of hospitalized patients with AOVF and the impact of malnutrition on their functional prognosis. This study aimed to evaluate the nutritional status of hospitalized elderly patients with AOVF using the Controlling Nutritional Status (CONUT) score and to determine the usefulness of the CONUT score in predicting their functional prognosis. METHODS: The CONUT score on admission was retrospectively calculated for 134 hospitalized elderly patients (mean age 83 ± 7.6 years, 66% female) with AOVF who received conservative treatment between 2017 and 2020. Functional outcome was assessed by comparing ambulatory ability before the onset of AOVF and upon discharge. Patients were divided into two groups: CONUT-high ( ≥ 4) and CONUT-low ( ≤ 3), according to receiver operating characteristic (ROC) analysis to predict decline in ambulatory ability upon discharge. Logistic regression analysis was performed to obtain odds ratios (OR) and 95% confidence intervals (CI) of the relationships between the nutritional status and ambulatory ability. The discriminative power of the CONUT score was then compared with other nutritional assessment tools such as the Geriatric Nutritional Risk Index (GNRI) and prognostic nutritional index (PNI) by ROC analysis. RESULTS: 81% of hospitalized patients with an AOVF were malnourished at the time of admission. The CONUT-high group had a significantly higher rate of decline in ambulatory ability (P < 0.001) than the CONUT-low group. Logistic regression analysis revealed the CONUT score ( ≥ 4) as an independent risk factor for a decline in ambulatory ability (OR 3.44, 95% CI 1.61-7.37, P = 0.0014). ROC analysis showed that the area under the curve (AUC) for the CONUT score (AUC = 0.724) was significantly greater than that for the GNRI (AUC = 0.624, P = 0.021) and PNI (AUC = 0.636, P = 0.0008). CONCLUSIONS: This study showed that 81% of hospitalized elderly patients with AOVFs were malnourished and that the CONUT score was a useful predictive factor of functional prognosis.

The impact of diabetes mellitus on spinal fracture with diffuse idiopathic skeletal hyperostosis: A multicenter retrospective study.

BACKGROUND: Patients with diffuse idiopathic skeletal hyperostosis (DISH) are susceptible to spinal column injuries with neurological deterioration. Previous studies indicated that the prevalence of diabetes mellitus (DM) in patients with DISH was higher than that in patients without DISH. This study investigates the impact of DM on surgical outcomes for spinal fractures in patients with DISH. METHODS: We retrospectively evaluated 177 spinal fractures in patients with DISH (132 men and 45 women; mean age, 75 ± 10 years) who underwent surgery from a multicenter database. The subjects were classified into two groups according to the presence of DM. Perioperative complications, neurological status by Frankel grade, mortality rate, and status of surgical site infection (SSI) were compared between the two groups. RESULTS: DM was present in 28.2% (50/177) of the patients. The proportion of men was significantly higher in the DM group (DM group: 86.0% vs. non-DM group: 70.1%) (p = 0.03). The overall complication rate was 22.0% in the DM group and 19.7% in the non-DM group (p = 0.60). Poisson regression model revealed that SSI was significantly associated with DM (DM group: 10.0% vs. non-DM group: 2.4%, Relative risk: 4.5) (p = 0.048). Change in neurological status, mortality rate, instrumentation failure, and nonunion were similar between both groups. HbA1c and fasting blood glucose level (SSI group: 7.2% ± 1.2%, 201 ± 67 mg/dL vs. non-SSI group: 6.6% ± 1.1%, 167 ± 47 mg/dL) tended to be higher in patients with SSI; however, there was no significant difference. CONCLUSIONS: In spinal fracture in patients with DISH, although DM was an associated factor for SSI with a relative risk of 4.5, DM did not negatively impact neurological recovery. Perioperative glycemic control may be useful for preventing SSI because fasting blood glucose level was high in patients with SSI.

Risk factors for delayed diagnosis of spinal fracture associated with diffuse idiopathic skeletal hyperostosis: A nationwide multiinstitution survey.

BACKGROUND: Patients with DISH are susceptible to spinal fractures and subsequent neurological impairment, including after minor trauma. However, DISH is often asymptomatic and fractures may have minimal symptoms, which may lead to delayed diagnosis. The purpose of this study was to identify risk factors for delayed diagnosis of spinal fractures in patients with diffuse idiopathic skeletal hyperostosis (DISH). METHODS: The subjects were 285 patients with DISH surgically treated at 18 medical centers from 2005 to 2015. Cause of injury, imaging findings, neurological status at the times of injury and first hospital examination, and the time from injury to diagnosis were recorded. A delayed diagnosis was defined as that made >24 h after injury. RESULTS: Main causes of injury were minor trauma due to a fall from a standing or sitting position (51%) and high-energy trauma due to a fall from a high place (29%) or a traffic accident (12%). Delayed diagnosis occurred in 115 patients (40%; 35 females, 80 males; mean age 76.0 ± 10.4 years), while 170 (60%; 29 females, 141 males; mean age 74.6 ± 12.8 years) had early diagnosis. Delayed group had a significantly higher rate of minor trauma (n = 73, 63% vs. n = 73, 43%), significantly more Frankel grade E (intact neurological status) cases at the time of injury (n = 79, 69% vs. n = 73, 43%), and greater deterioration of Frankel grade from injury to diagnosis (34% vs. 8%, p < 0.01). In multivariate analysis, a minor trauma fall (OR 2.08; P < 0.05) and Frankel grade E at the time of injury (OR 2.29; P < 0.01) were significantly associated with delayed diagnosis. CONCLUSION: In patients with DISH, it is important to keep in mind the possibility of spinal fracture, even in a situation in which patient sustained only minor trauma and shows no neurological deficit. This is because delayed diagnosis of spinal fracture can cause subsequent neurological deterioration.

Clinical outcomes after posterior cervical decompression and fusion surgery for destructive spondyloarthropathy in patients undergoing long-term hemodialysis: A matched case-control study.

BACKGROUND: Cervical destructive spondyloarthropathy (DSA) often leads to cervical myelopathy in long-term hemodialysis patients. However, the surgical outcomes after instrumented fusion surgery for cervical DSA are still unclear. The objective of this study was to investigate the clinical outcomes of cervical DSA in comparison with a control group. MATERIALS AND METHODS: A consecutive series of 20 undergoing long-term hemodialysis patients who underwent instrumented fusion surgery for cervical DSA between 2010 and 2016 were included in this study (DSA group). The mean age at surgery was 65 years, and there were 11 men and 9 women. The average length of hemodialysis was 23 years. The age- and sex-matched control group consisted of 20 patients (degenerative conditions). The Japanese Orthopedic Association (JOA) score, recovery rate, complications, and loss of correction of fused level were compared between the groups. RESULTS: Two of the 20 patients died due to perioperative complications. More than 1 year of follow-up data after surgery was available for 18 patients. The mean JOA score significantly increased from 5.4 before surgery to 9.7 at 1 year after surgery and 8.3 at the final follow-up (mean: 33.2 ± 21.3 months, P = 0.019). There were no significant differences in the mean recovery rate (41% vs. 37%, P = 0.44) between the DSA group and control group. Loss of correction of more than 5°was significantly higher in the DSA group (44% vs. 10%, P = 0.027). The rate of pseudarthrosis (17% vs. 5%, P = 0.328) and adjacent segment disease (22% vs. 10%, P = 0.17) tended to be higher in the DSA group. DISCUSSION: The clinical outcomes showed significant recovery in both groups. Therefore, posterior cervical decompression and fusion surgery was effective for treating cervical DSA.

Spinal fractures in patients with Diffuse idiopathic skeletal hyperostosis:A nationwide multi-institution survey.

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) increases the spine's susceptibility to unstable fractures that can cause neurological deterioration. However, the detail of injury is still unclear. A nationwide multicenter retrospective study was conducted to assess the clinical characteristics and radiographic features of spinal fractures in patients with DISH. METHODS: Patients were eligible for this study if they 1) had DISH, defined as flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies, and 2) had an injury in the ankylosing spine. This study included 285 patients with DISH (221 males, 64 females; mean age 75.2 ± 9.5 years). RESULTS: The major cause of injury was falling from a standing or sitting position; this affected 146 patients (51.2%). Diagnosis of the fracture was delayed in 115 patients (40.4%). Later neurological deterioration by one or more Frankel grade was seen in 87 patients (30.5%). The following factors were significantly associated with neurological deficits: delayed diagnosis (p = 0.033), injury of the posterior column (p = 0.021), and the presence of ossification of the posterior longitudinal ligament (OPLL) (p < 0.001). The majority of patients (n = 241, 84.6%) were treated surgically, most commonly by conventional open posterior fixation (n = 199, 69.8%). Neurological improvement was seen in 20.0% of the conservatively treated patients, and in 47.0% of the patients treated surgically. CONCLUSIONS: Minor trauma could cause spinal fractures in DISH patients. Delayed diagnosis, injury of the posterior column, and the presence of OPLL were significantly associated with neurological deterioration. Patients with neurological deficits or unstable fractures should be treated by fixation surgery.

Comparison of the AOSpine subaxial cervical spine injury classification system and the Allen classification.

The AOSpine group has launched a new subaxial cervical spine injury system (AOSCIS) based on morphology. The objective of this study was to use the AOSCIS and compare it to the widely used Allen classification (AC) based on mechanics for subaxial cervical spine injury. Twenty-two consecutive patients with subaxial cervical spine injury who received posterior cervical fixation in our hospital were included in this study. Medical records were evaluated retrospectively. The evaluated factors were as follows: preoperative ASIA impaired scale (AIS), AOSCIS, AC, and diffuse idiopathic skeletal hyperostosis (DISH). There was AIS A in nine patients, AIS C in four patients, AIS D in four patients, and AIS E in five patients. Two patients with AOSCIS B2 were classified as AC DF1. Two AOSCIS F3 patients were classified as AC CE1. Eighteen AOSCIS C patients were classified into multiple categories: five as AC DF2, three as DF3, one as CF4, one as CF5, four as DE2, three as CE3 + DE1, and one as CE3 + VC2. All of the AOSCIS A0 (F) or B patients were classified as AC stage 1, and all of the AOSCIS C patients were classified as AC stage 2 and higher (P < 0.05). All of six patients with DISH were classified as AOSCIS C and CE3, DE2, or DF3. AOSCIS and AC are correlated. Conducting an evaluation using both systems helps us to better comprehend subaxial cervical spine injuries.

Prognosis and adjacent segment disease after lumbar spinal fusion surgery for destructive spondyloarthropathy in long-term hemodialysis patients.

BACKGROUND: Lumbar destructive spondyloarthropathy (DSA) is a serious complication in long-term hemodialysis patients. There have not been many reports regarding the surgical management for lumbar DSA. In addition, the adjacent segment pathology after lumbar fusion surgery for DSA is unclear. The objective of this study was to assess the clinical outcome and occurrence of adjacent segmental disease (ASD) after lumbar instrumented fusion surgery for DSA in long-term hemodialysis patients. MATERIALS AND METHODS: A consecutive series of 36 long-term hemodialysis patients who underwent lumbar instrumented fusion surgery for DSA were included in this study. The mean age at surgery was 65 years. The mean follow-up period was 4 years. Symptomatic ASD was defined as symptomatic spinal stenosis or back pain with radiographic ASD. The Japanese Orthopedic Association score (JOA score), recovery rate (Hirabayashi method), complications, and reoperation were reviewed. RESULTS: The mean JOA score significantly increased from 13.5 before surgery to 21.3 at the final follow-up. The mean recovery rate was 51.4%. Six of the 36 patients died within 1 year after index surgery. One patient died due to perioperative complication. Symptomatic ASD occurred in 43% (13 of 30) of the cases. Of these 13 cases, 5 had adjacent segment disc degeneration and 8 had adjacent segment spinal stenosis. Three cases (10%) required reoperation due to proximal ASD. Multi-level fusion surgery increased the risk of ASD compared with single-level fusion surgery (59% vs. 23%). The recovery rate was significantly lower in the ASD group than the non-ASD group (38% vs. 61%). DISCUSSION: This study demonstrated that symptomatic ASD occurred in 43% of patients after surgery for lumbar DSA. A high mortality rate and complication rate were observed in long-term hemodialysis patients. Therefore, care should be taken for preoperative planning for surgical management of DSA.

Outcome and treatment of postoperative spine surgical site infections: predictors of treatment success and failure.

BACKGROUND: Surgical site infection (SSI) is an important complication after spine surgery. The management of SSI is characterized by significant variability, and there is little guidance regarding an evidence-based approach. The objective of this study was to identify risk factors associated with treatment failure of SSI after spine surgery. PATIENTS AND METHODS: A total of 225 consecutive patients with SSI after spine surgery between July 2005 and July 2010 were studied retrospectively. Patients were treated with aggressive surgical debridement and prolonged antibiotic therapy. Outcome and risk factors were analyzed in 197 patients having 1 year of follow-up. Treatment success was defined as resolution within 90 days. RESULTS: A total of 126 (76 %) cases were treated with retention of implants. Forty-three (22 %) cases had treatment failure with five (2.5 %) cases resulting in death. Lower rates of treatment success were observed with late infection (38 %), fusion with fixation to the ilium (67 %), Propionibacterium acnes (43 %), poly microbial infection (68 %), >6 operated spinal levels (67 %), and instrumented cases (73 %). Higher rates of early resolution were observed with superficial infection (93 %), methicillin-sensitive Staphylococcus aureus (95 %), and <3 operated spinal levels (88 %). Multivariate logistic regression revealed late infection was the most significant independent risk factor associated with treatment failure. Superficial infection and methicillin-sensitive Staphylococcus aureus were predictors of early resolution. CONCLUSION: Postoperative spine infections were treated with aggressive surgical debridement and antibiotic therapy. High rates of treatment failure occurred in cases with late infection, long instrumented fusions, polymicrobial infections, and Propionibacterium acnes. Removal of implants and direct or staged re-implantation may be a useful strategy in cases with high risk of treatment failure.

Minimally Invasive Thoracic-Lumbar Stabilization Surgery for Infected Charcot Spine Arthropathy (ICSA) After Spinal Cord Injury.

Charcot spinal arthropathy (CSA) is a very rare condition that causes destruction and deformity of the spine due to impaired sensation. We report a case of an infected Charcot spine arthropathy (ICSA) treatment with spinal reconstruction surgery using a minimally invasive surgery (MIS) technique. A 49-year-old man who had a spinal cord injury (SCI) at age 19 presented with a destructive lesion in the L2/3 and a fistula in his lower back. Spinal reconstruction surgery using a penetrating endplate screw, lateral lumbar interbody fusion (LLIF), and a computer-assisted rod bending system were performed. A CT scan taken six months after surgery showed bony fusion. Reconstruction of the destructive spine is necessary to control the infection and symptoms due to kyphotic deformity for ICSA. Although the treatment of ICSA generally requires a highly invasive approach, we have achieved good clinical results with minimally invasive reconstructive surgery.

Optimizing preoperative bone health assessment for adult spinal deformity: a prospective correlation analysis of intraoperative pedicle screw insertion torque and imaging modalities in Japan.

Study Design: Prospective cohort study. Purpose: This study aimed to identify the optimal preoperative bone health assessment for adult spinal deformity (ASD) surgery through correlation analysis between intraoperative pedicle screw (PS) insertion torque and various bone quality measures, including bone mineral density (BMD) assessed by dual-energy X-ray absorptiometry (DEXA), Hounsfield unit (HU) by computed tomography (CT), and vertebral bone quality (VBQ) score by magnetic resonance imaging. Overview of Literature: Existing data on optimal assessment tools for ASD surgery are limited. Methods: The study included patients with ASD aged >60 years who underwent spinal corrective fusion surgery from the lower thoracic spine to the pelvis. The intraoperative PS insertion torque was measured using a torque meter. Pearson correlation coefficients were calculated between the PS insertion torque and the BMD, HU, and VBQ score. Preoperative bone quality was compared between the proximal junctional failure (PJF) and non-PJF groups. Results: Thirty-one patients with 177 PS at T10, T11, and T12 were analyzed. The PS insertion torque showed a moderate positive correlation with lumbar spine BMD (r=0.59-0.69, p<0.01), total hip BMD (0.58-0.62, p<0.01), and HU value (r=0.58-0.66, p<0.01). However, the VBQ score did not show significant correlation (r=-0.28 to -0.23, p >0.05). Notably, a strong correlation was found between the PS insertion torque and the HU value for screws of the same size (r=0.71 and 0.74, p<0.01). The HU value at T12 and the PS insertion torque at T10 were significantly lower in the PJF group than in the non-PJF group. Conclusions: This study demonstrates a positive correlation between the PS insertion torque and HU value in the lower thoracic spine and a moderate correlation with BMD but not the VBQ score. Preoperative assessment using DEXA and CT is crucial for optimizing bone health management in ASD surgery.

Risk factors of Domino osteoporotic vertebral fractures is severe paraspinal muscle fatty degeneration.

BACKGROUND CONTEXT: Domino osteoporotic vertebral fractures (OVFs) involve multiple OVFs occurring simultaneously or sequentially, before healing of the initial OVFs. However, the risk factors and long-term clinical outcomes of domino OVFs are unclear. PURPOSE: To identify the risk factors associated with domino OVFs and to assess their impact on patients' quality of life (QOL). STUDY DESIGN/SETTING: Multicenter prospective observational cohort study. PATIENT SAMPLE: Patients (n = 190) treated conservatively for acute OVFs in eight hospitals with 12-month follow-up. OUTCOME MEASURES: Clinical outcomes were assessed using the visual analog scale (VAS), Oswestry Disability Index (ODI), and Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ). Multivariate analyses were performed to identify risk factors for domino OVFs. METHODS: All patients underwent magnetic resonance imaging (MRI) at 3 months to detect subsequent domino OVFs. Domino OVF group included initial domino OVFs (multiple acute OVFs at baseline) and subsequent domino OVFs at 3 months. Paraspinal muscle assessment was performed using the lumbar indentation value and Goutallier classification. Patient characteristics, bone quality, paravertebral muscle degeneration, nutritional status, radiographic parameters, and QOL scores were compared between the non-domino and domino OVF groups. RESULTS: We evaluated 50 (26.3%) patients with domino OVFs (34 with initial domino OVFs; 20 with subsequent domino OVFs). Walking ability was poorer in the domino than in the non-domino OVF group, from baseline to the 12 months follow-up. Groups with three or more adjacent domino OVFs showed worse VAS and ODI scores. Multivariate logistic regression analysis revealed that severe fatty degeneration of the paraspinal muscle was an independent risk factor for domino OVFs. CONCLUSIONS: Severe paraspinal muscle fatty degeneration is an independent risk factor for domino OVFs. Our study showed that the quality, rather than the quantity, of paraspinal muscles had an impact on domino OVFs. Early assessment of fatty degeneration in the paraspinal muscles is essential for predicting the development of domino OVFs.

Comparison of osteoanabolic agents (teriparatide and romosozumab) with bisphosphonates in prevention of subsequent vertebral fractures in patients treated for osteoporotic vertebral fracture for 12 months: An observational cohort study.

Introduction: Domino osteoporotic vertebral fracture (OVF) is as a subsequent fracture that develops within 3 months before the initial OVF heals. There is limited evidence regarding the efficacy of osteoanabolic agents on its treatment. This study evaluated the effects of bisphosphonates and anabolic agents teriparatide and romosozumab on subsequent domino OVF. Methods: This was post hoc analysis of a prospective, multicenter, observational study conducted across 8 hospitals, enrolling 144 patients with conservatively treated OVF, grouped into patients receiving bisphosphonate (BP, n = 55), teriparatide (TPTD, n = 62), and romosozumab (Romo, n = 27). The primary outcome was the incidence of subsequent OVF at 3 and 12 months, whereas the secondary outcomes included the incidence of pseudoarthrosis and progression of vertebral collapse (VC). Pseudoarthrosis was classified as stable or unstable based on vertebral instability. Results: The use of osteoanabolic agents did not reduce the incidence of subsequent OVF at 3 and 12 months. There were no significant differences in the background data or type of conservative treatment among the three groups. However, the TPTD and Romo groups had significantly lower rates of unstable pseudarthrosis (p = 0.03). Additionally, there were no significant differences in VC progression between groups, but it tended to be higher in the BP group than the TPTD and Romo group (p = 0.07). Conclusion: Osteoanabolic agents were beneficial in reducing unstable pseudoarthrosis, but were not more effective than bisphosphonates in the development of subsequent domino OVF. A more comprehensive approach to the treatment of osteoporosis is needed to prevent domino OVFs.

Effects of Perioperative Teriparatide Treatment on the Hounsfield Unit Values at the Upper Instrumented Vertebra in Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective single-center study. OBJECTIVE: This study aimed to assess the effects of pre and postoperative teriparatide (TPTD) treatment on Hounsfield units (HU) after surgery for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: The most commonly used method for assessing bone mineral density is dual-energy x-ray absorptiometry. HU values at the upper instrumented vertebra (UIV) have been proposed as a surrogate method for assessing bone quality, particularly in patients with ASD. However, the effect of TPTD treatment on vertebral HU values remains unclear. MATERIALS AND METHODS: We identified 57 consecutive patients with ASD who underwent long-instrumented fusion surgery (>5 vertebrae) between 2014 and 2020. Patients were retrospectively divided into a non-TPTD group (n = 31) and a TPTD group (n = 26). HU measurements were obtained at a level above the UIV (UIV + 1). Changes in the HU value at 1-year postoperatively were compared between the TPTD and non-TPTD groups. The duration of preoperative TPTD was compared between the proximal junctional proximal junctional failure (PJF) and non-PJF groups. RESULTS: Preoperative HU values were significantly lower in the TPTD group than in the non-TPTD group, despite no significant difference in preoperative bone mineral density of the proximal femur between the two groups. Changes in HU values were significantly higher in the TPTD group than in the non-TPTD group (20.8 ± 15.7% vs -2 ± 10.2%, P < 0.001). In the subanalysis of the TPTD group, the duration of preoperative TPTD treatment was significantly shorter in the PJF group than in the non-PJF group (34.7 ± 16.8 days vs 86.9 ± 34.7 days, P = 0.004). CONCLUSIONS: Pre and post-operative TPTD treatment increased the average HU value at UIV + 1 by 20.8%. Therefore, more prolonged preoperative TPTD treatment improves bone quality and may help prevent osteoporosis-related complications.

Increased serum levels of miR-1266 in patients with psoriasis vulgaris.

MicroRNAs (miRNAs) are post-transcriptional regulators that bind to complementary sequences in the 3' UTRs of mRNAs, leading to gene silencing, and their serum levels can be useful biomarkers for diagnosis, prognosis and therapeutic value in various diseases. Although miRNAs are thought to be involved in the pathogenesis of human diseases, little is known about miRNAs in psoriasis. Recently, psoriasis has attracted attention for its characteristics as a Th17 disease; the expression of IL-17 is increased in lesional skin and serum. We hypothesized that miRNAs contribute to the mechanism underlying the overexpression of IL-17. Therefore, serum levels of miR-1266, a putative regulator of IL-17A, in psoriasis patients were determined with the expectation that miR-1266 levels may be decreased in these patients, which may result in induction of IL-17. However, real-time PCR demonstrated that serum miR-1266 levels were considerably higher in psoriasis patients than in healthy control subjects. Furthermore, miR-1266 levels showed weak inverse correlations with Psoriasis Area Severity Index scores and body surface areas of involved skin. Taken together, serum miR-1266 may have potential for a new disease marker. miR-1266 is not likely to regulate IL-17A expression directly, but may be involved in the pathogenesis of psoriasis by regulating other target molecules.

Cervical lateral mass screw fixation without fluoroscopic control: analysis of risk factors for complications associated with screw insertion.

OBJECTIVE: To examine the outcome of cervical lateral mass screw fixation focusing on analysis of the risk factors for screw-related complications. METHODS: Ninety-four patients who underwent posterior cervical fixation with a total of 457 lateral mass screws were included in the study. The lateral mass screws were placed using a modified Magerl method. Computed tomographic (CT) images were taken in the early postoperative period in all patients, and the screw trajectory angle was measured on both axial and sagittal plane images. RESULTS: In the postoperative CT analysis for the screw trajectory, 56.5 % of the screws were directed within the acceptable range (within 21-40° on both axial and sagittal planes). As intraoperative screw-associated complications, 9.6 % of the screws were found to contact with or breach the vertebral artery foramen. In this group, the screw trajectory angle on axial plane was significantly lower than in the group without contact. Facet violation was observed in 13 screws (2.8 %). This complication was associated with a significantly lower trajectory angles in the sagittal plane, predominantly at C6 level (69.2 %). In the patient chart review, no serious neurovascular injuries were documented. CONCLUSIONS: In the analysis of potential risk factors for violation of the VA foramen as well as FV during screw insertion, the former incidence was significantly related to the screw trajectory angle (lack of lateral angulation) in the axial plane, while the latter incidence was related to a poor screw trajectory angle in the sagittal plane.

Surgical Outcome and Features of C7 Spondylolisthesis with Myelopathy: A Case Series.

Introduction: Reports of myelopathy with C7 anterior spondylolisthesis are extremely rare, and the surgical outcomes, clinical features, and their effects remain unknown. We describe six patients who underwent surgery for C7 spondylolisthesis with myelopathy. Methods: Six patients who underwent operative treatment for C7 spondylolisthesis with myelopathy were retrospectively reviewed. C7 spondylolisthesis was defined as an anterior slippage of more than 2 mm on X-ray or computed tomography (CT). The images were evaluated using radiography, magnetic resonance imaging (MRI), and CT. Clinical outcomes were evaluated using the thoracic Japanese Orthopedic Association (T-JOA) score and Frankel grade. Results: Facet joint arthrosis was observed in all patients at the C7/T1 level. MRI revealed a juxta-facet cyst in the spinal segment in three cases and a high signal change in four cases. We could visualize C7 anterior slippage from the lateral radiograph in one case. The mean time from onset to diagnosis was 95 (range, 7-280) months. Posterior spinal fusion using pedicle screws and interlaminectomy was performed in five cases. Cystectomy with partial laminectomy was performed in one case with a juxta-facet cyst. The mean JOA score was 6±0.7 preoperatively and improved to 9±1.5 at the final follow-up. The Frankel grades of all patients improved by more than one grade. Conclusions: In this study, myelopathy with C7 spondylolisthesis was relatively severe, and we believe that the mechanical stress between the rigid thoracic vertebrae and the movable cervical spine may cause C7 spondylolisthesis. Posterior spinal fusion and partial laminectomy for C7 spondylolisthesis with myelopathy resulted in satisfactory outcomes.