Japanese orthopaedic association cervical myelopathy evaluation questionnaire (JOACMEQ): Part 5. Determination of responsiveness.

BACKGROUND: In 1999, the Japanese Orthopaedic Association decided to develop a new Cervical Myelopathy Evaluation Questionnaire (JOACMEQ). The final version of the JOACMEQ, comprising 24 questions and five domains (cervical spine function (CF); upper extremity function (UF); lower extremity function (LF); bladder function (BF); and quality of life (QOL)), was established after three nationwide investigations. The fourth investigation, reported in this paper, was performed to confirm the responsiveness of the questionnaire. METHODS: A total of 137 patients with cervical myelopathy were included in the study. Each patient was interviewed twice using the JOACMEQ before and after treatment. At the second interview, the patients self-rated their condition in five domains for "worse," "somewhat worse," "no change," "somewhat better," or "better," and these scores were defined as the external assessment rating. The difference of the points in five domains between the first and the second interview was calculated against each external assessment. Based on the results, substantial clinical benefit (SCB) thresholds for the JOACMEQ were determined. RESULTS: The statistically significant median values of the acquired points were 17.5 for CF, 16.0 and 21.0 for UF, 27.0 and 20.5 for LF, 13.0 for BF, and 29.0 for QOL. After consideration of the results, the committee decided that an acquired point ≥20 could be interpreted as representing an SCB threshold for the JOACMEQ. CONCLUSION: We have concluded that a treatment can be judged to be effective for a patient if 1) The patient give all answers for the questions necessary to calculate the functional score of a domain and an increase of ≥20 points is obtained for that score, or 2) The functional score after treatment is > 90 points even if the answer for the unanswered questions was supposed to be the worst possible choice.

Conventional JOA score for cervical myelopathy has a rater's bias -In comparison with JOACMEQ.

BACKGROUND: The JOA (Japan Orthopaedic Association) score has been a standard outcome measure to evaluate cervical myelopathy in Japan. Despite its reliability and convenience, there can be a rating bias in the JOA score. The current study was conducted to delineate the rater's bias of the JOA score by comparing it with a new objective outcome measure. METHODS: Two hundred and thirty four operative candidates with cervical myelopathy were included in the study. The patients were divided into four groups according to the surgeon (92 patients in group A, 60 patients in group B, 38 patients in group C and 44 patients in group D). Each patient's preoperative JOA score was exclusively recorded by the surgeon himself, while JOACMEQ (Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire) was recorded by each patient. Disease severity, the most important prognostic factor, was equalized between patient groups by a special statistical method called inverse-probability weighting (IPW). To define similarity of the two groups, Cohen's d was used. RESULTS: After the adjustment, the differences of the JOA score were only 0.1 between groups A and D and 0 between groups B and C. The values of Cohen's d were also very small both between groups A and D (3%), and between groups B and C (0.3%). The averaged JOA scores of groups A and D were higher by 0.4-0.8 than those of groups B and C, while the averaged JOA scores were almost the same both between groups A and D, and between groups B and C. Surgeons A and D had the same tendency to give higher JOA scores than surgeons B and C did. CONCLUSIONS: The current study confirmed there is a definite rater's bias in the JOA score. JOACMEQ is to be applied as a more reliable outcome measure to evaluate myelopathy patients.

Verification of the sensitivity of functional scores for treatment results - Substantial clinical benefit thresholds for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ).

BACKGROUND: Validity and reliability of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) had already been verified as the patients' self-rating assessment of low back pain and lumbar spinal disease and, the present study demonstrated the responsiveness of this measure. METHODS: 192 subjects who were determined by medical instructors of the Japanese Society for Spine Surgery and Related Research were analyzed. They had completed a series of treatment and both surveys before and after the treatment. Authors investigated rates of concordance between assessment by physicians and subjective assessment by patients. The mean, standard deviation, minimum, 25th percentile, median, 75th percentile and maximum values for pre-treatment, post-treatment, and acquired points were calculated, and then, we also investigated the trend between subjective assessment by patients and mean acquired points for each JOABPEQ domain and substantial clinical benefit thresholds for the JOABPEQ. RESULTS: Symptom changes as assessed by physicians did not coincide with those by patients, and acquired points in each JOABPEQ domain were significantly increased with improved self-rating by patients. In addition, patients who rated symptom changes as "slightly improved" showed a mean acquired points of ≥20, and those reporting "improved" showed a 25th percentile points of the acquired points of ≥20 approximately. CONCLUSION: A significant correlation was noted between the self-rating of patients and acquired points JOABPEQ, suggesting that ≥20 acquired points can be interpreted as substantial clinical benefit thresholds for the JOABPEQ.

Japanese orthopaedic association back pain evaluation questionnaire (JOABPEQ) as an outcome measure for patients with low back pain: reference values in healthy volunteers.

BACKGROUND: In 2007, the Japanese orthopaedic association back pain evaluation questionnaire (JOABPEQ) was established to overcome the limitations of the original JOA scoring system developed in 1986. Although this new self-administered questionnaire is a more accurate outcome measure for evaluating patients with low back pain, physicians were unable to as certain the exact status of a patient at a single time point because of a lack of reference values. This study aimed to establish the reference values of JOABPEQ in different age and gender groups using data obtained from healthy volunteers. METHODS: This study was conducted in 21 university hospitals and affiliated hospitals from October 2012 to July 2013. The JOABPEQ includes 25 questions that yield five domains to evaluate individuals with low back pain from five different perspectives. A total of 1,456 healthy volunteers (719 men, 737 women; age range, 20-89 years) answered the questionnaire. The differences in scores according to age and gender were examined by non-parametric tests. RESULTS: The JOABPEQ scores significantly decreased with age in the domains of lumbar spine dysfunction, gait disturbance, and social life dysfunction. In these three domains, the median scores approached the 100 possible points in individuals aged 20-70 for both genders. However, the median scores for lumbar spine dysfunction and social life dysfunction decreased to 83.0 and 65.0-78.0 points, respectively, in individuals in their 80 s and 70-80 s, respectively; and the scores for gait disturbance decreased to 93.0 and 71.0 points for males and females in their 80 s. Overall, the median scores for pain-related and psychological disorders were 100 and 60.0-72.0 points, respectively. CONCLUSION: The reference values for JOABPEQ according to age and gender were established herein. Patients with low back pain should be evaluated with this new self-administered questionnaire taking these reference values into account.

An outcome measure for patients with cervical myelopathy: the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ): an average score of healthy volunteers.

BACKGROUND: An outcome measure to evaluate the neurological function of patients with cervical myelopathy was proposed by the Japanese Orthopaedic Association (JOA score) and has been widely used in Japan. However, the JOA score does not include patients' satisfaction, disability, handicaps, or general health, which can be affected by cervical myelopathy. In 2007, a new outcome measure, the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), which is a self-administered questionnaire, was developed. However, the influence of age and gender on the scores has not been fully examined. The purpose of this study was to establish the standard value of the JOACMEQ by age using healthy volunteers. METHODS: This study was conducted in 23 university hospitals and their affiliated hospitals from September to December 2011. The questionnaire included 24 questions for evaluation of physical function of the cervical spine and spinal cord. A total of 1,629 healthy volunteers were recruited for the study. The ages ranged from 20 to 89 years old. RESULTS: The volunteers comprised 798 men and 831 women. In the elderly healthy volunteers, the JOACMEQ scores decreased with age. In general, the scores for cervical spine function and upper/lower extremity function were retained up to the 60s, then decreased in the 70s and 80s. The scores for quality of life were retained up to the 70s; however, the score for bladder function was retained up to the 40s, then declined with age from the 50s to 80s. CONCLUSION: The standard values of the JOACMEQ by age were established. Differences in the scores were found among different generations. Patients with cervical myelopathy should be evaluated with this new self-administered questionnaire taking into account the standard values according to different ages.

Neurological manifestations of thoracic myelopathy.

INTRODUCTION: Investigation of preoperative manifestations of thoracic myelopathy in a large population has not been reported. The aim of this study was to identify symptoms specific to anatomical pathology or compressed segments in thoracic myelopathy through investigation of preoperative manifestations. MATERIALS AND METHODS: Subjects were 205 patients [143 men, 62 women; mean age, 62.2 (range 21-87 years)] with thoracic myelopathy who underwent surgery at our affiliate institutions from 2000 to 2011. The disease distribution included ossification of the ligamentum flavum (OLF) in 106 patients, ossification of the posterior longitudinal ligament (OPLL) in 17, OLF with OPLL in 17, intervertebral disc herniation (IDH) in 23, OLF with IDH in 3, and spondylosis in 39. We assessed (1) initial and preoperative complaints, (2) neurological findings, (3) Japanese Orthopaedic Association scores (JOA, full score, 11 points), (4) the compressed segments, and (5) preoperative duration. Multivariate analyses were performed to examine potential relationships between preoperative manifestations and anatomical pathology or compressed segments. RESULTS: The multivariate analyses revealed relationships between lower limb muscle weakness and T10/11 anterior compression; lower limb pain and T11/12 anterior compression; low back pain and T11/12 compression; and hyporeflexia in the patellar tendon reflex/foot drop and T12/L1 anterior compression. CONCLUSION: This study elucidated symptoms specific to anatomical pathology or compressed segments in thoracic myelopathy. These relationships can be helpful in the initial investigation of thoracic diseases, although additional measures such as MRI or CT are necessary for definitive diagnosis.

Finger-tapping motion analysis in cervical myelopathy by magnetic-sensor tapping device.

STUDY DESIGN: Case-control study. OBJECTIVES: The purpose of this study is to determine finger motion of patients with cervical myelopathy during finger-tapping cycles. SUMMARY OF BACKGROUND DATA: A major symptom of patients with compressive cervical myelopathy is finger clumsiness. Therefore, understanding finger motion is prerequisite in assessing the severity of myelopathy. The popular grip-and-release test evaluates only the number of motion cycles, which is insufficient to fully describe complex finger motion. METHODS: Forty-three patients with cervical myelopathy and 41 healthy controls tapped their index fingers against their thumbs as rapidly as possible for 30 seconds and the motion was recorded by a magnetic-sensor coil attached to the nail surface. Output signals were stored in a computer, which automatically calculated tapping frequency, distance moved, ratio of opening/closing velocity and the SD of the tapping interval. RESULTS: The SD of the tapping interval was significantly greater and all other measures were significantly smaller in patients with cervical myelopathy, than in healthy controls. All indices significantly improved after surgical decompression of the cervical spine. Distance moved (Pearson correlation coefficient: r=0.590, P<0.001) and the SD of the tapping interval (r=-0.451; P=0.002) were significantly correlated with the Japanese Orthopedic Association score (neurological scale). CONCLUSION: The quantitative evaluation of finger paralysis was performed by this tapping device. Speed and regularity in repetitive motion of fingers were correlated with the severity of cervical myelopathy.

Validity, reliability and responsiveness of the Japanese version of the Neck Disability Index.

BACKGROUND: The Neck Disability Index (NDI) is one of the most widely used questionnaires for neck pain. The purpose of this study was to validate the Japanese NDI. METHODS: We performed two surveys with an 8-week interval in 130 patients with neck pain, radiculopathy and myelopathy. We asked patients to answer two versions of the Japanese NDI: the original NDI, which had been completed by a forward-backward translation procedure, and the modified NDI, which has the phrase "because of neck pain" to the phase "because of neck pain or numbness in the arm." The other parameters examined were the strength of pain and numbness, the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire, the Hospital Anxiety and Depression Scale, and Short Form 36. Attending surgeons judged the symptom severity. Patients were asked to report the patient global impression of change (PGIC) at the second survey. The internal consistency, criterion-related and discriminative validity, and reliability were evaluated. RESULTS: The original NDI and the modified NDI were 26.9 ± 17.1 and 29.9 ± 15.5, respectively. The Cronbach α values of the original NDI and the modified NDI were 0.92 and 0.89, respectively. Both versions of the NDI had good to excellent correlative coefficients with the related domains. The modified NDI had a higher validity for numbness and mental health-related QOL. The symptom severity was significantly correlated with the modified NDI. The intraclass correlation coefficients of the two surveys of the modified and original NDI were comparable. The effect sizes of the modified and the original NDI were 0.64 and 0.55, respectively. Spearman's ρ between the change of the NDI and the PGIC was 0.47 in the original NDI and 0.59 in the modified NDI. CONCLUSIONS: We demonstrated the validity, reliability and responsiveness of the Japanese NDI. The modified NDI was more strongly correlated with numbness and mental health-related QOL.

Preoperative factors affecting the two-year postoperative patient-reported outcome in single-level lumbar grade I degenerative spondylolisthesis.

Background: The choice of operative method for lumbar spinal stenosis with Meyerding grade I degenerative spondylolisthesis remains controversial. The purpose of this study was to identify the preoperative factors affecting the 2-year postoperative patient-reported outcome in Meyerding grade I degenerative spondylolisthesis. Methods: Seventy-two consecutive patients who had minimally invasive decompression alone (D group; 28) or with fusion (DF group; 44) were enrolled. The parameters investigated were the Japanese Orthopaedic Association back pain evaluation questionnaire as patient-reported assessment, and L4 slippage (L4S), lumbar lordosis (LL), and lumbar axis sacral distance (LASD) as an index of sagittal alignment for radiological evaluation. Data collected prospectively at 2 years postoperatively were examined by statistical analysis. Results: Sixty-two cases (D group; 25, DF group; 37) were finally evaluated. In multiple logistic regression analysis, preoperative L4S and LASD were extracted as significant preoperative factors affecting the 2-year postoperative outcome. Patients with preoperative L4S of 6 mm or more have a lower rate of improvement in lumbar spine dysfunction due to low back pain (risk ratio=0.188, p=.043). Patients with a preoperative LASD of 30 mm or more have a higher rate of improvement in lumbar dysfunction due to low back pain (risk ratio=11.48, p=.021). The results of multiple logistic analysis by operative method showed that there was a higher rate of improvement in lumbar spine dysfunction due to low back pain in patients with preoperative LASD of 30 mm or more in DF group (risk ratio=172.028, p=.01). Conclusions: Preoperative L4S and LASD were extracted as significant preoperative factors affecting patient-reported outcomes at 2 years postoperatively. Multiple logistic analyses by the operative method suggested that DF may be advantageous in improving lumbar dysfunction due to low back pain in patients with preoperative LASD of 30 mm or more.

Medium-term outcomes of C3-6 laminoplasty for cervical myelopathy: a prospective study with a minimum 5-year follow-up.

C3-6 laminoplasty preserving muscle insertions into the C7 spinous process is reportedly associated with a significantly decreased frequency of postoperative axial neck pain. However, no prospective study has reported medium-term outcomes of C3-6 laminoplasty. The purpose of this study was to elucidate medium-term outcomes after C3-6 laminoplasty. Subjects comprised 31 patients with cervical myelopathy who underwent C3-6 laminoplasty preserving all bilateral muscles attached to the C2 and C7 spinous processes and were followed for ≥5 years. Clinical and radiological data were prospectively collected. Neurological status was assessed using Japanese Orthopaedic Association (JOA) score. Axial neck pain was graded as severe, moderate or mild. Sagittal alignment of the cervical spine and progression of ossification of the posterior longitudinal ligament (OPLL) were assessed by comparing serial lateral radiographs. Mean JOA score improved significantly from 10.6 before surgery to 14.7 at the time of maximum recovery, and slightly declined to 14.3 at final follow-up. In six patients who developed late deterioration, these conditions were unrelated to the cervical spine. As of final follow-up, only one patient (3.2%) had complained of axial neck pain persisting for 5 years. Although progression of OPLL was found in 63.6% of patients, none had experienced neurological deterioration due to this progression. At final follow-up, sagittal alignment of the cervical spine was more lordotic than before surgery. Medium-term outcomes of C3-6 laminoplasty were satisfactory. Frequencies of persistent axial neck pain and loss of cervical lordosis after surgery remained significantly decreased for ≥5 years postoperatively.

Disc space distraction is a potent risk factor for adjacent disc disease after PLIF.

UNLABELLED: We reported that excessive disc space distraction caused by insertion of large cages during posterior lumbar interbody fusion (PLIF) combined with pedicle screws (PS) induces adjacent segment disease (ASD). Spinous process plate (SPP) is known to allow cage subsidence when used in PLIF, since they cannot share vertical loads. We therefore hypothesize that the incidence of ASD after PLIF with SPP should be lower than that after PLIF with PS due to this loss of disc space distraction. MATERIALS AND METHODS: Radiographic ASD is defined as development of spondylolisthesis > 3 mm, decrease in disc height > 3 mm, or intervertebral angle at flexion lesser than -5°. Symptomatic ASD is defined by a decrease of ≥ 4 points in Japanese Orthopedic Association score. One hundred and thirty patients with L4 spondylolisthesis were treated with either PLIF with SPP (n = 45) or PLIF with PS (n = 85) and followed up for a minimum of 2 years (mean, 39.0 months). RESULTS: L4-5 disc space distraction in the SPP group was significantly smaller (0.4 mm) as compared to the PS group (1.8 mm). The incidence of clinical ASD in the SPP group (2%, 1/45) was also significantly less than that in the PS group (15%, 13/85). Multivariate analysis showed that disc space distraction was the most significant risk factor. CONCLUSIONS: Among various risk factors for ASD after PLIF, the excessive distraction of disc space proved to be a potent risk factor for ASD.

Does Atherosclerosis Have Negative Impacts on Early Adjacent Segment Degeneration After Posterior Lumbar Interbody Fusion?

STUDY DESIGN: Retrospective study. OBJECTIVE: To examine whether atherosclerosis has negative impacts on early adjacent segment degeneration (ASD) after posterior lumbar interbody fusion using traditional trajectory pedicle screw fixation (TT-PLIF). METHODS: The subjects were 77 patients who underwent single-level TT-PLIF for degenerative lumbar spondylolisthesis. Using dynamic lateral radiographs of the lumbar spine before surgery and at 3 years postoperatively, early radiological ASD (R-ASD) was examined. Early symptomatic ASD (S-ASD) was diagnosed when neurologic symptoms deteriorated during postoperative 3-year follow-up and the responsible lesions adjacent to the fused segment were also confirmed on magnetic resonance imaging. According to the scoring system by Kauppila et al, the abdominal aortic calcification score (AAC score: a surrogate marker of systemic atherosclerosis) was assessed using preoperative lateral radiographs of the lumbar spine. RESULTS: The incidence of early R-ASD was 41.6% at the suprajacent segment and 8.3% at the subjacent segment, respectively. Patients with R-ASD had significantly higher AAC score than those without R-ASD. The incidence of early S-ASD was 3.9% at the suprajacent segment and 1.4% at the subjacent segment, respectively. Patients with S-ASD had higher AAC score than those without S-ASD, although there was no significant difference. CONCLUSIONS: At 3 years after surgery, the advanced AAC had significantly negative impacts on early R-ASD after TT-PLIF. This result indicates that impaired blood flow due to atherosclerosis can aggravate degenerative changes at the adjacent segments of the lumbar spine after PLIF.

Amelioration in Ankle Pain and Improvement in Function After Total Knee Arthroplasty for Ipsilateral Knee and Ankle Osteoarthritis: A Report of Two Cases.

We report 2 cases of ipsilateral ankle and knee osteoarthritis (OA), with the chief complaint being chronic ankle and knee pain. In the first patient, the ankle pain was more severe than the knee pain, whereas the second patient had more severe pain in the knee than in the ankle. In both cases, varus malalignment of the knee and varus tilt of the ankle joint were detected on standing radiographs. The severity of OA was found to be grade 4 in the knee, according to the Kellgren-Lawrence grading system, and stage IIIa in the ankle, according to the modified Takakura ankle OA classification system. Navigation-assisted total knee arthroplasty was performed in both cases, leading to a decreased degree of varus malalignment in the knee and ankle, as well as a significantly improved patient-based outcome in both joints. Correction of malalignment of the ankle by total knee arthroplasty relieved the severe pain and restored optimal function in the ankle without surgical intervention.

Two-level Posterior Lumbar Interbody Fusion at the Lumbosacral Segment has a High Risk of Pseudarthrosis and Poor Clinical Outcomes: Comparison Between the Lumbar and Lumbosacral Segments.

STUDY DESIGN: This was a retrospective study. OBJECTIVES: The purposes of this study were to investigate the fusion rate and clinical outcomes of 2-level posterior lumbar interbody fusion (PLIF). SUMMARY OF BACKGROUND DATA: PLIF provides favorable clinical outcomes and a high fusion rate. However, most extant studies have been limited to the results of single-level PLIF. Clinical outcomes and fusion rate of 2-level PLIF are unknown. MATERIALS AND METHODS: In total, 73 patients who underwent 2-level PLIF below L3 between 2008 and 2016 (follow-up period >2 y) were included. Patients were divided into the 2 groups on the basis of surgical level. The lumbar group included 48 patients who underwent L3/4/5 PLIF, and the lumbosacral group included 25 patients who underwent L4/5/S PLIF. Fusion rate and clinical outcomes were compared. The Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and a visual analog scale were used for evaluation. RESULTS: Fusion rate was significantly lower in the lumbosacral group (lumbar 96% vs. lumbosacral 64%; P<0.001). Eight of 9 cases of pseudarthrosis occurred at the lumbosacral segment. Improvement in the mental health domain of the JOAPEQ was significantly lower in the lumbosacral group (lumbar 16 vs. lumbosacral 10; P=0.02). The VAS data showed that improvements in the following variables were significantly lower in the lumbosacral group than in the lumbar group: pain in low back (lumbar -38 vs. lumbosacral -23; P=0.004), pain in buttocks or lower leg (lumbar -48 vs. lumbosacral -29; P=0.04), and numbness in buttocks or lower leg (lumbar -44 vs. lumbosacral -33; P=0.04). CONCLUSIONS: Two-level PLIF at the lumbosacral segment demonstrated a significantly lower fusion rate and poorer clinical outcomes than that at the lumbar-only segments. Some reinforcement for the sacral anchor is recommended to improve fusion rate, even for short fusion like 2-level PLIF, if the lumbosacral segment is included. LEVEL OF EVIDENCE: Level III.

Postoperative displacement of hydroxyapatite spacers implanted during double-door laminoplasty.

OBJECT: Double-door laminoplasty using hydroxyapatite (HA) spacers has been widely performed for compressive cervical myelopathy and has provided good neurological outcome. Although HA spacers are used for preventing reclosure of the opened laminae, they are often displaced or dislocated from their original position. The authors investigated the incidence and patterns of postoperative HA spacer displacement to determine the reasons for this unfavorable event. METHODS: Eighty-six patients with compressive myelopathy underwent double-door laminoplasty in which a total of 278 HA spacers were used. The displacement of HA spacers and opened laminae were assessed using postoperative lateral radiographs and CT scans. RESULTS: Postoperative dorsal migration > 2 mm was found in 116 (42%) of 278 implanted HA spacers. In addition, 33 (38%) of 86 HA spacers rotated > 10 degrees and 29 (34%) of the 86 opened laminae tilted > 10 degrees. Moreover, deformation of the newly formed spinal canal was observed in 51 (59%) of 86 cases, and bone fusion between the HA spacer and spinous process was achieved in only 15 (8.7%) of 172 cases. Neurological worsening and neck pain, however, were not associated with displacement of HA spacers or deformation of the spinal canal. CONCLUSIONS: In double-door laminoplasty, postoperative displacement of the HA spacer with deformation of the enlarged spinal canal occurred frequently. Hydroxyapatite spacers tend to become displaced after surgery. Placing the HA spacer at the base of the spinous process close to the dura mater may prevent postoperative displacement.

Early cephalad adjacent segment degeneration after posterior lumbar interbody fusion: a comparative study between cortical bone trajectory screw fixation and traditional trajectory screw fixation.

OBJECTIVE: Cortical bone trajectory (CBT) screw insertion through a caudomedial starting point provides advantages in limiting dissection of the superior facet joints and reducing muscle dissection and the risk of superior-segment facet violation by the screw. These advantages of the cephalad CBT screw can result in lower rates of early cephalad adjacent segment degeneration (ASD) after posterior lumbar interbody fusion (PLIF) with CBT screw fixation (CBT-PLIF) than those after PLIF using traditional trajectory screw fixation (TT-PLIF). Here, the authors investigated early cephalad ASD after CBT-PLIF and compared these results with those after TT-PLIF. METHODS: The medical records of all patients who had undergone single-level CBT-PLIF or single-level TT-PLIF for degenerative lumbar spondylolisthesis (DLS) and with at least 3 years of postsurgical follow-up were retrospectively reviewed. At 3 years postoperatively, early cephalad radiological ASD changes (R-ASD) such as narrowing of disc height (> 3 mm), anterior or posterior slippage (> 3 mm), and posterior opening (> 5°) were examined using lateral radiographs of the lumbar spine. Early cephalad symptomatic adjacent segment disease (S-ASD) was diagnosed when clinical symptoms such as leg pain deteriorated during postoperative follow-up and the responsible lesion suprajacent to the fused segment was confirmed on MRI. RESULTS: One hundred two patients underwent single-level CBT-PLIF for DLS and were followed up for at least 3 years (CBT group). As a control group, age- and sex-matched patients (77) underwent single-level TT-PLIF for DLS and were followed up for at least 3 years (TT group). The total incidence of early cephalad R-ASD was 12.7% in the CBT group and 41.6% in the TT group (p < 0.0001). The incidence of narrowing of disc height, anterior slippage, and posterior slippage was significantly lower in the CBT group (5.9%, 2.0%, and 4.9%) than in the TT group (16.9%, 13.0%, and 14.3%; p < 0.05). Early cephalad S-ASD developed in 1 patient (1.0%) in the CBT group and 3 patients (3.9%) in the TT group; although the incidence was lower in the CBT group than in the TT group, no significant difference was found between the two groups. CONCLUSIONS: CBT-PLIF, as compared with TT-PLIF, significantly reduced the incidence of early cephalad R-ASD. One of the main reasons may be that cephalad CBT screws reduced the risk of proximal facet violation by the screw, which reportedly can increase biomechanical stress and lead to destabilization at the suprajacent segment to the fused segment.

Perioperative complications of primary posterior lumbar interbody fusion for nonisthmic spondylolisthesis: analysis of risk factors.

OBJECT: Although posterior lumbar interbody fusion (PLIF) is an excellent procedure to attain circumferential decompression, it is technically demanding and can lead to various surgical complications. The authors retrospectively reviewed consecutive patients with nonisthmic spondylolisthesis who underwent PLIF to reveal the incidence and risk factors for perioperative complications of PLIF. METHODS: A total of 240 patients underwent PLIF. The fusion level was at L4-5 in 220, L3-4 in 18, and L5-S1 in 2. The medial walls of the fusion segment's facet joints were resected, and the VSP Spine System was used for the pedicle screw instrumentation. The operations were performed by 7 surgeons, who were divided into 4 groups according to their level of experience with spinal surgery. RESULTS: The average operation time was 175 +/- 49 minutes, and the estimated blood loss was 746 +/- 489 ml. A total of 90 patients (37.5%) experienced complications; 41 (17%) experienced transient neurological complications, and 18 (7.5%) experienced permanent neurological complications. The mean neurological score according to the Japanese Orthopaedic Association improved from 14.3 +/- 3.8 to 24.7 +/- 4.0 in the patients without complications and from 14.8 +/- 3.6 to 24.0 +/- 3.9 in the patients with complications. Multivariate analysis concerning the relationship between complications and risk factors (operation time, estimated intraoperative blood loss, and surgeon experience) revealed that operation time was the only significant risk factor for complications. CONCLUSIONS: Perioperative complications of PLIF were more frequent in this homogeneous study group than in other studies of various implants. Total excision of the facet joints might preclude neurological complications.

Improvement of thoracic myelopathy following bariatric surgery in an obese patient.

Revision spine surgery is extremely challenging in super-super obese patients (body mass index (BMI) ≥60 kg/m2). This is the first report describing how bariatric surgery was useful for a super-super obese patient with progressing myelopathy. A 44-year-old man with a BMI of 62.9 kg/m2 presented with an ambulatory disorder caused by thoracic ossification of the posterior longitudinal ligament (T7-8). Before this paraparesis, he had undergone four spinal operations, and was not considered a good candidate for a fifth spine surgery. At the time of the fourth operation, he had reached a maximum weight of 205 kg (BMI 69.3 kg/m2). Instead, he underwent a laparoscopic sleeve gastrectomy. Sixteen months later, his body weight had decreased to BMI 35.2 kg/m2, and he could walk without a walker. In addition to reducing our patient's load, a 'non-operative' form of dekyphosis due to altered thoracic spinal alignment secondary to weight loss may explain the improvement in his myelopathy.

Motion analysis of grip and release with fingers using simple magnetic detection system.

We have developed a magnetic grip-and-release motion detection system to measure time differences among fingers during motion. We designed a magnetic sensing system consisting of a magnetic oscillation coil, sensing coil, and circuit unit. We measured wave forms of grip-and-release motion (15 s) of seven healthy volunteers using the system. To provide the grip-and-release timing of each finger, we used the reference voltage of each subject in the state of grasping a rod with a 30 mm diameter. Using the reference voltage, the time differences in the finger movements of all volunteers were detected. The detected grip-and-release time difference of both dominant and nondominant hands had a main tendency in which the closing movement of the little finger is fast, within 10 ms, and the opening movement is slow, within 13 ms. Our data suggest that the new magnetic sensing system has the potential to detect the quantitative value of the time difference in grip-and-release motion among fingers.

Clinical Outcomes After Posterior Lumbar Interbody Fusion: Comparison of Cortical Bone Trajectory and Conventional Pedicle Screw Insertion.

STUDY DESIGN: This study is a retrospective cohort study using prospectively collected data. OBJECTIVE: To compare the effectiveness of posterior lumbar interbody fusion (PLIF) using the cortical bone trajectory (CBT) and conventional pedicle screw (PS) techniques. SUMMARY OF BACKGROUND DATA: There are few published studies to date comparing PLIF using CBT technique with PLIF using the conventional PS technique. METHODS: We studied 119 consecutive patients who underwent single-level PLIF between 2010 and 2014 with a minimum 12-month follow-up. Forty-two patients underwent CBT-PLIF (the CBT group) and 77 underwent conventional PS-PLIF (the PS group). Clinical outcomes were assessed by the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) and visual analog scale (VAS). To assess perioperative pain, a 6-point Numeric Rating Scale score and the total amount of diclofenac sodium suppositories used were recorded. The operative time and blood loss were recorded. Muscle damage was evaluated by serum creatine kinase concentrations. Fusion status was evaluated using 3-dimensional computed tomography 12 months postoperatively. We used inverse probability of treatment weighting based on the propensity score to reduce confounding factors. RESULTS: There were no significant between-group differences in operative time or fusion rates, whereas the CBT group experienced significantly less blood loss, lower postoperative creatine kinase levels, less diclofenac sodium suppositories, and lower Numeric Rating Scale scores than the PS group did. The change in the JOABPEQ subdomain score for social life function 1 month postoperatively was the only significantly different factor among the JOABPEQ and VAS scores. CONCLUSIONS: Both procedures were comparable in terms of clinical outcomes and fusion rates, but CBT-PLIF provided the additional benefits of less blood loss, less intraoperative muscle damage, less perioperative pain, and earlier recovery to normal activities.