Relation between spine alignment and scapular position by plain radiograph examination.

Background: Both scapular dynamics and static scapular position are important in the treatment of shoulder dysfunction. This study aimed to create an index that can evaluate scapular position on plain radiographs and evaluate the relation between scapular position and posture accurately. Methods: Using four fresh frozen cadavers, we developed a glenoid angle grade based on the degree of overlap between the shadow of the coracoid inflection point and the upper edge of the scapula on frontal plain radiographs: grade 1, no overlap; grade 2, overlaps by less than half of the shadow; grade 3, overlaps by more than half. We then performed a retrospective cohort study that included 329 shoulders of 329 patients who underwent spine surgery. Spine alignment parameters (SPAPs), including cervical lordosis (CL), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence, pelvic tilt, sacral slope, and sagittal vertical axis were measured on standing lateral plain radiographs. Glenoid anterior tilt (GAT) and glenoid anteversion angle (GAVA) were calculated on frontal radiographs and three-dimensional computed tomography scans. Correlations between SPAPs and each angle were investigated, and independent influencing factors were sought in multivariate analysis. Individual factors, GAT, GAVA, and SPAPs were compared among the grades. Results: SPAPs associated with GAT were sagittal vertical axis (R = 0.14, P = .011), TK (R = 0.12, P = .026), and LL (R = -0.11, P = .046). Multivariate analysis identified TK and LL as independent influencing factors (TK, P = .001; LL, P = .008). SPAPs associated with GAVA were CL (R = 0.17, P = .002), TK (R = 0.29, P < .001), and LL (R = 0.25, P < .001). Multivariate analysis identified CL, TK, and LL as independent influencing factors (CL, P = .01; TK, P = .03; LL, P = .03). There were 183, 127, and 19 cases categorized as grades 1, 2, and 3. GAT (grade 1, 24.0 ± 7.8; 2, 32.4 ± 7.0; 3, 41.0 ± 7.8), GAVA (1, 29.3 ± 7.6; 2, 33.7 ± 9.5; 3, 31.5 ± 8.3), and TK (1, 30.6 ± 13.6; 2, 35.1 ± 14.2; 3, 43.1 ± 20.4) differed significantly according to grade. Conclusion: We identified factors that influence scapular position and demonstrated that scapular position can be estimated by a grading system using plain radiographs.

Reduction of perioperative blood loss and operating time for arthroscopic rotator cuff repair by intravenous administration of tranexamic acid.

Background: Tranexamic acid (TXA) is widely used in hip and knee arthroplasty to reduce perioperative bleeding. Recently, its use has been expanded to arthroscopic surgery. The purpose of this study was to evaluate the efficacy of preoperative use of TXA in arthroscopic rotator cuff repair (RCR). Methods: A cohort comprising 129 consecutive patients who underwent arthroscopic primary RCR at our institution was retrospectively investigated according to whether they received TXA (April 2018 to December 2020, TXA group, n = 64) or did not receive TXA (April 2016 to March 2018, non-TXA group, n = 65). TXA was administered at a dose of 1 g intravenously. Rotator cuff tears were repaired by the suture bridge technique. Videos of the arthroscopic procedures were reviewed and rated for visual clarity using a 10-point numeric rating scale. Arthroscopic procedures were divided into glenohumeral, resection of bursal tissue and acromioplasty, and RCR steps. Each step was rated separately. Age, sex, body mass index, hemoglobin level before and on days 1 and 7 after surgery, operating time, mean arterial pressure, tear size, and number of anchors used for cuff repair were compared between the two groups. Results: There were no statistically significant differences in the patient demographic data. The operating time was significantly shorter in the TXA group than in non-TXA group (97.8 ± 21.8 min vs 116.2 ± 26.0 min). The clarity of the visual field was similar between the two groups during the glenohumeral phase but was significantly higher in the TXA group during the resection of bursal tissue and acromioplasty and RCR phases. Hemoglobin level was not significantly different between the groups on postoperative day 1 but was significantly higher in the TXA group on day 7. Conclusion: Administration of a single intravenous dose of TXA improved visual clarity in arthroscopic RCR, decreased the total operating time, and reduced hemoglobin loss on postoperative day 7.

Partial thickness tear of the supraspinatus at the musculotendinous junction in a softball catcher.

We report a rare case of a partial thickness tear of the supraspinatus at the musculotendinous junction in a softball catcher. Preoperative magnetic resonance images of the shoulder showed high signal intensity areas at the musculotendinous junction, along with discontinuity of the articular side of the supraspinatus. Arthroscopic examination revealed articular-side partial tear at the musculotendinous junction. The patient was able to return to playing softball 20 weeks after arthroscopic side-to-side repair. J. Med. Invest. 68 : 386-388, August, 2021.

Bilateral Osteochondritis Dissecans of the Capitellum in Fraternal Twins: A Case Report.

CASE: We report the cases of 15-year-old male fraternal twins with bilateral osteochondritis dissecans (OCD) of the capitellum in the absence of syndromic features. At the time of presentation, they had been actively engaged in competitive rhythmic gymnastics for 3 years. Both patients had chronic symptoms in the right elbow, and both underwent arthroscopic evaluation and management. CONCLUSION: The cases of these 2 patients provide evidence to support the theory that the etiology of OCD may have a genetic background.

Arthroscopic excision of unstable os acromiale associated with impingement syndrome: a case report.

Os acromiale is a rare anatomical variant that is caused by failure of fusion of the acromial apophysis and is usually asymptomatic. We report a case of impingement syndrome of the left shoulder secondary to unstable os acromiale, which was initially overlooked and confirmed only during arthroscopic examination. Arthroscopic excision of the unstable fragment was successful without residual dysfunction of the deltoid muscle.

Clinical Significance of High-intensity Zone for Discogenic Low Back Pain: A Review.

High-intensity zone (HIZ) was originally described as a high-intensity signal on T2-weighted magnetic resonance (MR) images, located in the posterior annulus fibrosus, clearly separated from the nucleus pulposus. Among symptomatic patients with low back pain, HIZ is present in 28-59% of cases. In morphologically abnormal discs, high sensitivity and specificity of 81% and 79%, respectively, were reported for HIZs and concordant pain during discography. In contrast, another report indicated low rates. Although most papers reported high sensitivity and specificity for this relationship, it remains controversial. Regarding the pathology of HIZs, inflammatory granulation tissues are found at sites showing HIZs. Such inflammatory tissues produce pro-inflammatory cytokines and mediators, which sensitize the nociceptors within the disc and cause pain. An effective treatment for this condition is yet to be established. Recently, minimally invasive surgery using percutaneous endoscopic discectomy (PED) under local anesthesia was introduced. After removal of the degenerated disc material, the HIZ is identified with the endoscope and then coagulated and modulated with a bipolar radio pulse. This technique is called thermal annuloplasty. In conclusion, HIZs is an important sign of painful intervertebral disc disruption, if identified precisely based on factors such as location and intensity.

Tendon retraction with rotator cuff tear causes a decrease in cross-sectional area of the supraspinatus muscle on magnetic resonance imaging.

BACKGROUND: Muscle atrophy and fatty degeneration of the rotator cuff muscles have been reported as negative prognostic indicators after rotator cuff repair. Although the Y-shaped view is widely used for measuring the cross-sectional area of the supraspinatus muscle, the contribution of retraction of the torn tendon as well as muscle atrophy must be considered. The purpose of this study was to clarify the relationship between cross-sectional area and tendon retraction or size of the tear. METHODS: This study included 76 shoulders that were evaluated arthroscopically for the presence and size of tears. Cross-sectional areas of rotator cuff muscles were measured from the Y-shaped view to 3 more medial slices. The occupation ratio and tangent sign were evaluated on the Y-shaped view. The retraction of torn tendon was also measured on the oblique coronal images. RESULTS: On the Y-shaped view, the cross-sectional area of the supraspinatus and the occupation ratio decreased in conjunction with the increase in tear size. A significant decrease in cross-sectional area was noted only in large and massive tears on more medial slices from the Y-shaped view. Significant decreases in the cross-sectional area of the infraspinatus were observed in large and massive tears on all images. A negative correlation was found between tendon retraction and cross-sectional area, which was strongest on the Y-shaped view. CONCLUSIONS: To avoid the influence of retraction of the supraspinatus tendon, sufficient medial slices from the musculotendinous junction should be used for evaluation of muscle atrophy.

Postoperative discal cyst: An unusual complication after microendoscopic discectomy in teenagers.

Various complications after microendoscopic discectomy (MED) are well known, but postoperative discal cyst is a unique and relatively unknown complication. Here, we report on two teenage patients who presented with postoperative discal cyst after MED for herniated nucleus pulposus (HNP), which resolved after conservative treatment. The patients were diagnosed with HNP at L4-5 and L5-S1 based on MRI and then treated by MED. Postoperative discal cyst was diagnosed on MRI after recurrence of symptoms. Both patients were managed conservatively. T2-weighted MRI demonstrated hyperintense collections adjacent to the operated intervertebral disc level, which were communicating with the corresponding disc annulus. Because the clinical symptoms were relatively mild, the patients were managed conservatively; both made a complete clinical recovery with radiological evidence of improvement. Postoperative discal cyst is a relatively unknown complication after MED for HNP. Surgeons should be aware of this postoperative complication when operating on young individuals with HNP.

Hysterical conversion paralysis in an adolescent boy with lumbar spondylolysis.

We describe a case of recurrent hysterical paralysis triggered by low back pain because of lumbar spondylolysis. A 16-year-old male soccer player was referred to our institution with five previous episodes of acute paralysis triggered by severe low back pain. We performed direct surgical repair of the terminal-stage bilateral spondylolysis at L4 using a hook-rod system. His chronic low back pain was completely resolved, and no further episodes of hysterical paralysis have occurred after surgery. Spine surgeons should be aware of possible hysterical conversion paralysis when there is discrepancy between radiological and neurological findings.

Double arthroscopic transtendon repair of partial-thickness articular surface tears of the rotator cuff: a surgical technique.

This study describes a technique of simultaneous arthroscopy and bursoscopy for transtendon repair of a partial-thickness articular surface rotator cuff tear. All procedures are under simultaneous visualisation from both the glenohumeral joint and the subacromial space to reduce the risk of intraoperative complications.

Detached Anterior Horn of the Medial Meniscus Mimicking a Parameniscal Cyst.

We report a case of a detached anterior horn of the medial meniscus with anterior knee pain. Preoperative magnetic resonance images of the knee were initially interpreted as a parameniscal cyst. Arthroscopic examination revealed subluxation of the anterior horn of the medial meniscus due to detachment from its anterior tibial insertion. Arthroscopic fixation with a suture anchor was successful and the cystic lesion was no longer visible on postoperative images.

State of the art: Intraoperative neuromonitoring in spinal deformity surgery.

Application of deformity correction spinal surgery has increased substantially over the past three decades in parallel with improvements in surgical techniques. Intraoperative neuromonitoring (IOM) techniques,including somatosensory evoked potentials (SEPs), muscle evoked potentials (MEPs), and spontaneous electromyography (free-run EMG), have also improved surgical outcome by reducing the risk of iatrogenic neural injury. In this article, we review IOM techniques and their applications in spinal deformity surgery. We also summarize results of selected studies including hundreds of spinal correction surgeries. These studies indicate that multimodal IOM of both motor and sensory responses is superior to either modality alone for reducing the incidence of neural injury during surgery. J. Med. Invest. 62: 103-108, August, 2015.

Foraminoplastic transforaminal percutaneous endoscopic discectomy at the lumbosacral junction under local anesthesia in an elite rugby player.

Percutaneous endoscopic discectomy (PED) is the least invasive disc surgery available at present. The procedure can be performed under local anesthesia and requires only an 8 mm skin incision. Furthermore, damage to the back muscle is considered minimal, which is particularly important for disc surgery in athletes. However, employing the transforaminal (TF) PED approach at the lumbosacral junction can be challenging due to anatomical constraints imposed by the iliac crest. In such cases, foraminoplasty is required in addition to the standard TF procedure. A 28-year-old man who was a very active rugby player visited us complaining of lower back and left leg pain. His visual analog scale (VAS) score for pain was 8/10 and 3/10, respectively. MRI revealed a herniated nucleus pulposus at L5-S level. TF-PED was planned; however, the anatomy of the iliac crest was later found to prevent access to the herniated mass. Foraminoplasty was therefore performed to enlarge the foramen, thereby allowing a cannula to be passed through the foramen into the canal without causing exiting nerve injury. The herniated mass was then successfully removed via the TF-PED procedure. Pain resolved after surgery, and his VAS score decreased to 0/10 for both back and leg pain. The patient returned to full rugby activity 8 weeks after surgery. In conclusion, even with an intracanalicular herniated mass at the lumbosacral junction, a TF-PED procedure is possible if additional foraminoplasty is adequately performed to enlarge the foramen.

Successful Outcomes Using Interlocking Prostheses for Periprosthetic Fractures with Loose Femoral Components.

Periprosthetic femoral fractures with implant loosening are difficult to treat, especially when accompanied by severe bone loss. We report here the treatment outcomes of 4 patients (1 man, 3 women; age range 69-86 years) with periprosthetic femoral fractures and implant loosening after bipolar hemiarthroplasty. Fractures were classified according to the Vancouver classification as type B2 and B3, with adequate or compromised bone stock, respectively. One patient was initially treated conservatively but symptoms due to implant loosening persisted and revision surgery was required. All patients underwent revision using a long-stem cementless implant with interlocking screws as well as a cancellous allograft to augment the bone stock. At final follow-up (mean, 25 months), all patients had stable implant fixation, bony union of the fracture, and marked recovery of the proximal femoral bone stock through allograft use. This revision procedure achieved implant fixation and fracture healing with reconstitution of the femur even in the short term and even in cases with severe bone deficiency.

Percutaneous Endoscopic Discectomy via Transforaminal Route for Discal Cyst.

Background. Discal cyst has been identified as a rare cause of low back pain and radiating leg pain. The pathogenesis and management of this condition are still debated. The largest number of reported cases had undergone microsurgery while very few cases have been treated with percutaneous endoscopic discectomy (PED). Methods. An 18-year-old boy complained of low back pain radiating to right leg after a minor road traffic accident. Diagnosis of a discal cyst at L4-L5 level was made based on magnetic resonance imaging (MRI). Despite conservative management for 6 months, the low back pain and radiating leg pain persisted so surgical treatment by PED was performed under local anesthesia. As the patient was a very active baseball player, his physician recommended a minimally invasive procedure to avoid damage to the back muscles. Results. The patient's low back pain and leg pain disappeared immediately after surgery and he made a rapid recovery. He resumed mild exercise and sports practice 4 weeks after surgery. Complete regression of the cystic lesion was demonstrated on the 2-month postoperative MRI. Conclusion. A minimal invasive procedure like PED can be an effective surgical treatment for discal cyst, especially in active individuals who play sports.

Percutaneous endoscopic lumbar discectomy for a huge herniated disc causing acute cauda equina syndrome: a case report.

Microsurgery for lumbar disc herniation that requires surgical intervention has been well described. The methods vary from traditional open discectomy to minimally invasive techniques. All need adequate preanesthetic preparation of patients as general anesthesia is required for the procedure, and nerve monitoring is necessary to prevent iatrogenic nerve injury. Conventional surgical techniques sometimes require the removal of the corresponding lamina to assess the nerve root and herniated disc, and this may increase the risk for posterior instability of the vertebral body. Should this occur, fusion surgery may be needed, further increasing morbidity and cost. We present here a case of lumbar herniated disc fragments causing acute cauda equina syndrome that were endoscopically resected through a transforaminal approach in an awake patient under local anesthesia. Percutaneous endoscopic discectomy under local anesthesia proved to be a better alternative to open back surgery as it made immediate intervention possible, was associated with fewer perioperative complications and morbidity, minimized soft tissue damage, and allowed early rehabilitation with a better outcome and greater patient satisfaction. In addition to these advantages, percutaneous endoscopic discectomy protects other approaches that may be needed in subsequent surgeries, whether open or minimally invasive.

Kidney-type intervertebral spacers should be located anteriorly in cantilever transforaminal lumbar interbody fusion: analyses of risk factors for spacer subsidence for a minimum of 2 years.

STUDY DESIGN: Retrospective analysis of factors related to kidney-type interbody spacer subsidence (SS) in transforaminal interbody fusion (TLIF). OBJECTIVE: To determine the risk factors for SS in TLIF using kidney-type spacers. SUMMARY OF BACKGROUND DATA: SS into the vertebral body, a major complication of TLIF, has not been studied extensively. METHODS: Between July 2004 and May 2006, 54 consecutive patients with lumbar dysplastic changes or degenerative disc diseases underwent TLIF using 82 kidney-type spacers with iliac bone grafts. All were followed-up for more than 2 years (mean, 2 y, 11 mo). SS was defined as disc height loss >2 mm. Risk factors analyzed for SS included spacer location in the intervertebral space (IVS, anterior, center, and posterior), sex, age, body mass index, and disease (spondylolisthesis, degenerative disc disease). Clinical outcomes were assessed using the Japanese Orthopedic Associated Score for back pain, as were adjacent segment disorder and nonunion. RESULTS: Of the 82 spacers, 66 were located in the center of the IVS and 16 anteriorly. There were 18 SS. Spacer position at the center of the IVS (P<0.001) and older age (P<0.001) were significantly associated with SS, with the first 2 factors having a synergistic effect. Adjacent level disorder (n=5) and nonunion (n=3) were observed only in patients with spacers positioned at the center of the IVS. CONCLUSIONS: Kidney-type spacers should be located in the anterior portion of the IVS to prevent subsidence of the intervertebral body, especially in patients with elderly age.

Surgical outcome of 2-stage (posterior and anterior) surgical treatment using spinal instrumentation for tuberculous spondylitis.

STUDY DESIGN: A prospective study on the clinical outcomes in patients with tuberculous spondylitis treated by a 2-stage operation (posterior and anterior) using posterior spinal instrumentation. OBJECTIVE: To evaluate the clinical outcomes of the 2-stage surgical treatment (first stage: placement of posterior instrumentation and second stage: anterior debridement and bone grafting) for tuberculous spondylitis. SUMMARY OF BACKGROUND DATA: There have been few reports describing the effects of 2-stage surgical treatment for tuberculous spondylitis. METHODS: Ten patients (5 men and 5 women) with tuberculous spondylitis were treated by 2-stage operations. Age at the initial operation was 64.6+/-14.8 years (average+/-SD) (range: 47 to 83 y). The clinical outcomes were evaluated before and after the surgery in terms of hematologic examination, pain level, and neurologic status. Bone fusion and changes in sagittal alignment were examined radiographically. RESULTS: All patients showed suppression of infection, bony fusion, relief of pain, and recovery of neurologic function. No significant changes were observed in kyphosis angle at the final follow-up. There were no incidences of severe complications or recurrence. CONCLUSIONS: Our results showed that posterior and anterior 2-stage surgical treatment for tuberculous spondylitis is a viable surgical option for cases in which conservative treatment has failed. However, the changes in sagittal alignment showed that this strategy provides limited kyphosis correction.

Unusual back pain caused by intervertebral disc degeneration associated with schmorl node at Th11/12 in a young athlete, successfully treated by anterior interbody fusion: a case report.

STUDY DESIGN: A case report describing thoracic intervertebral disc degeneration and spondylolisthesis associated with a Schmorl node in a young athlete, which was successfully treated by anterior interbody fusion (AIF). OBJECTIVE: To describe a rare pathologic condition with a clinical outcome of a surgical intervention. SUMMARY OF BACKGROUND DATA: Intervertebral degeneration and spondylolisthesis of the lower thoracic spine associated with a Schmorl node in a young athlete has not been reported. METHODS: A 19-year-old male amateur soccer player presented with severe back pain during motion. This pain was associated with intervertebral disc degeneration, spondylolisthesis, and a Schmorl node at the Th11/12 level. He was surgically treated by AIF. RESULTS: The AIF resulted in a solid fusion, an improvement in sagittal alignment, and amelioration of symptoms. CONCLUSION: The AIF procedure was effective for lower thoracic symptomatic intervertebral disc degeneration and spondylolisthesis associated with a Schmorl node.

Two-stage decompression for combined epiconus and cauda equina syndrome due to multilevel spinal canal stenosis of the thoracolumbar spine: a case report.

INTRODUCTION: A case of combined epiconus and cauda equina syndrome due to multilevel spinal canal stenosis of the thoracolumbar spine is reported. METHODS: A 76-year-old man with multilevel spinal canal stenosis of the thoracolumbar spine (Th11-12, L2-S) who showed symptoms of epiconus syndrome was reported. First, we performed anterior decompression and fusion at the thoracolumbar junction (decompression: Th11-12, fusion: Th10-L2), which ameliorated his symptom partially. However, he presented cauda equina symptoms. Then, he underwent posterior spinal decompression (L3-5) and fusion (Th12-L5). RESULTS: After anterior decompression, several symptoms disappeared. However, motor and sensory disturbance below L4 and bladder-bowel disturbance remained. We then performed a secondary operation. At three years' follow-up, he was able to walk with the aid of a cane. CONCLUSIONS: Combined epiconus and cauda equina syndrome due to multilevel spinal canal stenosis was treated by combined two-stage anterior and posterior decompression. In this case, multilevel decompression via anterior and posterior approaches was necessary to relieve the symptoms.