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PURPOSE: We defined sagittal S-line tilt (SSLT) as the tilt of the line connecting the upper instrumented vertebra and the lower instrumented vertebra. This study aimed to: (1) examine the correlation between SSLT and proximal junctional angle (PJA) change values, and (2) determine the cut-off value of SSLT with respect to proximal junctional kyphosis (PJK) occurrence. METHODS: Eighty-six consecutive patients (81 female and 5 male; mean age: 15.8 years) with Lenke 5C AIS who underwent posterior selective spinal fusion. Pearson's correlation coefficients were used to examine the relationship between preoperative SSLT and changes in PJA from preoperative to 2 years postoperative. The impact of SSLT on PJK at 2 years after surgery was assessed using a receiver operating characteristic (ROC) curve. RESULTS: We observed a moderate positive correlation between preoperative SSLT and change in PJA (R = 0.541, P < 0.001). We identified 18 patients (21%) with PJK at 2 years postoperative. Mean preoperative SSLT in the PJK group and the non-PJK group differed significantly at 23.3 ± 4.1° and 16.1 ± 5.0°, respectively (P < 0.001). The cut-off value of preoperative SSLT for PJK at 2 years postoperative was 18° in ROC curve analysis, with a sensitivity of 94%, specificity of 68%, and area under the ROC curve of 0.868. CONCLUSION: In selective lumbar fusion for AIS Lenke type 5C curves, preoperative SSLT was significantly correlated with PJA change from preoperative to 2 years postoperative. SSLT was a predictor of PJK occurrence, with a cut-off value of 18°.
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BACKGROUND: Atlantoaxial transarticular fixation, also called the Magerl technique, is said to be the most robust biomechanical method of fixation of the atlantoaxial vertebrae. However, the procedure carries a risk of spinal cord and vertebral artery injury during the insertion process, especially in patients with a high-riding vertebral artery. In this study, a computed tomography (CT)-based navigation system was used for preoperative planning and insertion. This investigation sought to determine the rate and direction of screw perforation as well as the incidence of screw loosening in computer-assisted atlantoaxial transarticular fixation. METHODS: Sixty patients (31 men and 29 women; mean ± SD age: 65.3 ± 19.6 years) who received atlantoaxial transarticular screw insertion with preoperative CT navigation were analyzed. We investigated screw position and loosening by CT at the final follow-up. RESULTS: Of the 108 screws inserted, the rate of Grade 2 or higher perforation was 4.6% (5/108). Nine of 81 (11.1%) screws inserted into the 44 patients who were followed for at least 6 months showed loosening. Logistic regression analysis revealed that unilateral insertion (odds ratio: 8.50, 95% confidence interval: 1.53-47.2, P = 0.014) was significantly associated with the incidence of screw loosening. CONCLUSIONS: The screw perforation rate of Grade 2 or higher in computer-assisted atlantoaxial transarticular screw fixation was 4.6%, with comparable frequencies of perforation direction. Unilateral insertion was a significant independent factor associated with screw loosening, which occurred in 11.1% of insertions. CLINICAL RELEVANCE: Spine surgeons should follow up with patients with caution because screws with unilateral insertion are prone to loosening.
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STUDY DESIGN: Retrospective cohort study with interrupted time series analysis. OBJECTIVE: To examine the clinical effectiveness of gelatin-thrombin matrix sealant (GTMS) on blood loss reduction after adolescent idiopathic scoliosis (AIS) surgery. SUMMARY OF BACKGROUND DATA: The real-world effectiveness of GTMS on blood loss reduction in AIS surgery has not been determined. PATIENTS AND METHODS: The medical records of patients receiving AIS surgery were retrospectively collected during a period before GTMS approval at our institution (January 22, 2010-January 21, 2015) as well as during a postintroduction period (January 22, 2015-January 22, 2020). The primary outcomes were intraoperative blood loss, drain output over 24 hours, and total blood loss (intraoperative blood loss + drain output over 24 h). Interrupted time series analysis using a segmented linear regression model was used to estimate the effect of GTMS on blood loss reduction. RESULTS: A total of 179 AIS patients [mean age (range): 15.4 (11-30) yr; 159 females and 20 males; 63 preintroduction patients and 116 postintroduction patients] were included. After its introduction, GTMS was used in 40% of cases. Interrupted time series analysis revealed changes of -340 mL (95% CI: -649 to -31, P = 0.03) for intraoperative blood loss, -35 mL (95% CI: -124 to 55, P = 0.44) for drain output over 24 hours, and -375 mL (95% CI: -698 to -51, P = 0.02) for total blood loss. CONCLUSIONS: The availability of GTMS was significantly associated with reduced intraoperative and total blood loss in AIS surgery. GTMS use as needed is recommended to control intraoperative bleeding in the setting of AIS surgery. LEVEL OF EVIDENCE: 3.
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Cifose , Escoliose , Fusão Vertebral , Adolescente , Feminino , Humanos , Masculino , Perda Sanguínea Cirúrgica , Gelatina , Análise de Séries Temporais Interrompida , Estudos Retrospectivos , Escoliose/cirurgia , Trombina , Resultado do Tratamento , Criança , Adulto Jovem , AdultoRESUMO
BACKGROUND CONTEXT: Adult spinal deformity (ASD) patients often complain of walking discomfort. However, dynamic balance evaluation methods of gait in ASD have not been well established. DESIGN: Case series study. PURPOSE: Characterize the gait of ASD patients using a novel two-point trunk motion measuring device. PATIENT SAMPLE: Sixteen ASD patients scheduled for surgery and 16 healthy control subjects. OUTCOME MEASURES: Trunk swing width and track length of the upper back and sacrum. METHODS: Gait analysis was performed using a two-point trunk motion measuring device on 16 ASD patients and 16 healthy control subjects. Three measurements were taken for each subject, and the coefficient of variation was determined to compare measurement accuracy between the ASD and control groups. Trunk swing width and track length were measured in three dimensions for comparisons between the groups. The relationship among output indices, sagittal spinal alignment parameters, and quality of life (QOL) questionnaire scores was examined as well. RESULTS: No significant difference was found for the precision of the device between the ASD and control groups. Compared with controls, the walking style of ASD patients tended to have larger right-left swing of the trunk (+14.0 cm and +23.3 cm at the sacrum and upper back, respectively), larger horizontal plane movement of the upper body (+36.4 cm), less vertical movement (-5.9 cm and -8.2 cm up-down swing at the sacrum and upper back, respectively), and longer gait cycle (+0.13 sec). Regarding QOL in ASD patients, greater right-left/front-back swing of the trunk, greater movement in the horizontal plane, and longer gait cycle were associated with lower QOL scores. Conversely, greater vertical movement was associated with higher QOL. CONCLUSIONS: ASD patients had unique gait characteristics, the intensity of which were associated with diminished QOL. The two-point trunk motion measuring device may be reliable and useful for the clinical assessment of balance during gait in ASD patients.
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Marcha , Qualidade de Vida , Humanos , Adulto , Reprodutibilidade dos Testes , Caminhada , SacroRESUMO
Introduction: Corrective scoliosis surgery in patients with adolescent idiopathic scoliosis (AIS) increases thoracic volume but does not improve respiratory function (RF). This study evaluates the effect of physical flexibility (PF) improvement after scoliosis surgery on RF. Methods: This study reviewed the records of 61 consecutive patients with AIS (56 female and 5 male; mean±standard deviation age: 14.8±2.2 years, range: 11-20 years) who had undergone posterior spinal fusion (PSF) of the thoracic curve. PF evaluated as finger-floor distance (FFD) was measured preoperatively and one year after surgery. After dividing the cohort into the PF improvement group and the PF nonimprovement group, RF changes at two years postoperative were statistically compared. Using logistic regression analysis, we evaluated the impact of a PF improvement on % forced vital capacity (%FVC) two years after surgery. Results: The rate of patients with increased FVC, %FVC, and forced expiratory volume 1.0 second two years after surgery was 79%, 51%, and 80%, respectively. The PF improvement group exhibited a significantly higher gain in %FVC versus the PF nonimprovement group (P=0.043). Moreover, PF improvement significantly prevented a %FVC decrease (odds ratio 8.43, 95% confidence interval 1.92-59.70; P<0.001), with an adjusted odds ratio of 11.86 (P<0.001). Conclusions: Patients with diminished PF after PSF for AIS may be less likely to achieve postoperative %FVC improvement. As increased postsurgical %FVC had a positive effect on physical function, treatment strategies that focus on maintaining and increasing PF are desirable from an RF viewpoint.
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OBJECTIVE: Wound dehiscence after cervical spine surgery is a well-known complication that can be a challenge for spine surgeons to manage, especially in cases of exposed implants. However, few studies have focused primarily on this phenomenon in cervical spine surgery to date. This investigation sought to determine the frequency of wound dehiscence following posterior cervical spine surgery and identify patient-based risk factors. METHODS: The medical data of 405 consecutive patients (290 male and 115 female; mean age: 68.9 years) who underwent posterior cervical spine surgery were retrospectively examined. Logistic regression models were employed to examine the prevalence, characteristics, and risk factors of postoperative wound dehiscence. RESULTS: We observed that 5.2% of cervical spine surgery patients experienced procedural postoperative wound dehiscence. In comparisons of dehiscence and non-dehiscence groups, significant differences were found for posterior instrumented fusion (81.0% vs. 45.3%; P < 0.01), extended T1 fusion (57.1% vs. 12.8%; P < 0.01), occipitocervical fusion (19.0% vs. 6.2%; P = 0.048), fused intervertebral levels (4.0 vs. 1.5; P < 0.01), surgical time (246 minutes vs. 165 minutes; P < 0.01), blood loss volume (228 mL vs. 148 mL; P = 0.023), and dialysis (14.3% vs. 1.8%; P = 0.011). Multivariate analysis identified extended T1 fusion and dialysis to be significantly associated with wound dehiscence with odds ratios of 5.82 and 10.70, respectively. CONCLUSIONS: The observed frequency of postoperative wound dehiscence in cervical spine surgery was 5.2%. As extended T1 fusion and dialysis may increase the risk of dehiscence after surgery, patients who display such risk factors may require additional observation and care.
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Complicações Pós-Operatórias , Fusão Vertebral , Humanos , Masculino , Feminino , Idoso , Estudos Retrospectivos , Complicações Pós-Operatórias/etiologia , Fusão Vertebral/efeitos adversos , Descompressão Cirúrgica/efeitos adversos , Fatores de Risco , Vértebras Cervicais/cirurgiaRESUMO
BACKGROUND: Delirium tremens is a symptom of alcohol withdrawal syndrome that occurs 48 to 96 hours after the last drink in 5% of withdrawing patients. METHODS: This report describes the clinical progression of a case of lumbar vertebral burst fracture with alcohol withdrawal delirium that was difficult to manage. RESULTS: A 47-year-old man was rushed to our hospital complaining of lumbar back pain and numbness in both lower extremities resulting from a 6-m fall during civil engineering work. Computed tomography (CT) revealed a L1 burst fracture with a highly protruding bone fragment in the spinal canal. Magnetic resonance imaging disclosed significant compression of the conus and intramedullary signal changes. We immediately performed posterior spinal fusion and vertebroplasty using instrumentation. On the 4th postoperative day, he became severely agitated, as diagnosed as having delirium tremens related to alcohol withdrawal syndrome, and soon began appropriate medication with diazepam. Although his symptoms persisted until 6 days postoperatively, follow-up CT detected no evidence of screw loosening or breakage. CONCLUSION: We encountered a patient with severe delirium tremens developing several days after thoraco-lumbar fusion surgery. Prompt internal fixation successfully treated the spinal injury and prevented neurological damage. It may also be necessary to consider treatment strategies for patients with a background of heavy alcohol consumption in consideration of delirium tremens and other symptoms of alcohol withdrawal.
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Delirium por Abstinência Alcoólica , Alcoolismo , Fraturas da Coluna Vertebral , Fusão Vertebral , Síndrome de Abstinência a Substâncias , Masculino , Humanos , Pessoa de Meia-Idade , Delirium por Abstinência Alcoólica/complicações , Síndrome de Abstinência a Substâncias/complicações , Fusão Vertebral/métodos , Fraturas da Coluna Vertebral/complicações , Fraturas da Coluna Vertebral/cirurgia , Fixação Interna de Fraturas/métodos , Vértebras Lombares/cirurgia , Vértebras Lombares/lesõesRESUMO
BACKGROUND: Although several studies have recently shown that spinous process-splitting laminectomy (SPSL) maintains lumbar spinal stability by preserving posterior ligament components and paraspinal muscles as compared with conventional laminectomy, evidence is scarce on the treatment outcomes of SPSL limited to lumbar degenerative spondylolisthesis. We herein compare the surgical results and global alignment changes for SPSL versus posterolateral lumbar fusion (PLF) without instrumentation for lumbar degenerative spondylolisthesis. METHODS: A total of 110 patients with Grade 1 lumbar degenerative spondylolisthesis who had undergone SPSL (47 patients) or PLF (63 patients) with minimum 1-year follow-up were retrospectively enrolled from a single institutional database. RESULTS: Mean operating time per intervertebral level and intraoperative blood loss per intervertebral level were comparable between the SPSL group and PLF group. Japanese Orthopaedic Association scores, Oswestry disability index, and visual analog scale scores were significantly and comparably improved at 1 year postoperatively in both groups as compared with preoperative levels. The numbers of vertebrae with slip progression to Grade 2 and slip progression of 5% or more at 1 year postoperatively were similar between the groups. In the SPSL group, mean pelvic tilt (PT) was significantly decreased at 1 year postoperatively. In the PLF group, mean lumbar lordosis (LL) was significantly increased, while mean sagittal vertical axis, PT, and pelvic incidence-LL were significantly decreased at 1 year after surgery. CONCLUSIONS: Compared with PLF without instrumentation, SPSL for Grade 1 lumbar degenerative spondylolisthesis displayed comparable results for slip progression and clinical outcomes at 1 year postoperatively.
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Lordose , Fusão Vertebral , Espondilolistese , Humanos , Espondilolistese/diagnóstico por imagem , Espondilolistese/cirurgia , Laminectomia , Estudos Retrospectivos , Fusão Vertebral/métodos , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Resultado do Tratamento , Lordose/cirurgiaRESUMO
BACKGROUND CONTEXT: An increasing number of medical centers are adopting an intraoperative computed tomography (iCT) navigation system (iCT-Navi) to provide three-dimensional navigation for pediatric scoliosis surgery. While iCT-Navi has been reported to provide higher pedicle screw (PS) insertion accuracy, it may also result in higher radiation exposure to the patient. What innovations and studies have been introduced to reduce radiation exposure and further improve PS insertion? PURPOSE: Evaluate the level of evidence and quality of papers while categorizing the tips and pitfalls regarding pediatric scoliosis surgery using iCT-Navi. Compare iCT-Navi with other methods, including preoperative CT navigation. STUDY DESIGN: Systematic review. PATIENT SAMPLE: Articles on pediatric scoliosis surgery with iCT-Navi published through to June 2022. OUTCOME MEASURES: PS perforation rate and patient intraoperative radiation dose. METHODS: Following PRISMA guidelines, the Cochrane Library, Google Scholar, and PubMed databases were searched for articles satisfying the criteria of iCT-Navi use and pediatric scoliosis surgery. The level of evidence and quality of the articles meeting the criteria were evaluated according to the guidelines of the North American Spine Society and American Academy of Orthopedic Surgeons, respectively. The articles were also categorized by theme and summarized in terms of PS insertion accuracy and intraoperative radiation dose. The origins and characteristics of five major classification methods of PS perforation grade were summarized as well. RESULTS: The literature search identified 811 studies, of which 20 papers were included in this review. Overall, 513 pediatric scoliosis patients (381 idiopathic, 44 neuromuscular, 39 neurofibromatosis type 1, 28 congenital, 14 syndromic, seven other) were evaluated for PS perforations among 6,209 iCT-Navi insertions. We found that 232 (3.7%) screws were judged as major perforations (G2 or G3), 55 (0.9%) screws were judged as dangerous deviations (G3), and seven (0.1%) screws were removed. There were no reports of neurovascular injury caused by PSs. The risk factors for PS perforation included more than six vertebrae distance from the reference frame, more than nine consecutive insertions, upper thoracic level, thinner pedicle, upper instrumented vertebra proximity, short stature, and female. The accuracy of PS insertion did not remarkably decrease when the radiation dose was reduced to 1/5 or 1/10 by altering the iCT-Navi protocol. CONCLUSIONS: iCT-Navi has the potential to reduce PS perforation rates compared with other methods. The use of low-dose radiation protocols may not significantly affect PS perforation rates. Although several risk factors for PS perforation and measures to reduce radiation dose have been reported, the current evidence is limited by a lack of consistency in classifying PS perforation and evaluating patient radiation dose among studies. The standardization of several outcome definitions is recommended in this rapidly developing field.
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Parafusos Pediculares , Exposição à Radiação , Escoliose , Fusão Vertebral , Cirurgia Assistida por Computador , Humanos , Criança , Feminino , Escoliose/diagnóstico por imagem , Escoliose/cirurgia , Escoliose/etiologia , Estudos Retrospectivos , Coluna Vertebral , Parafusos Pediculares/efeitos adversos , Tomografia Computadorizada por Raios X/efeitos adversos , Tomografia Computadorizada por Raios X/métodos , Exposição à Radiação/efeitos adversos , Exposição à Radiação/prevenção & controle , Cirurgia Assistida por Computador/efeitos adversos , Fusão Vertebral/efeitos adversosRESUMO
Aim: Grisel's syndrome is a non-traumatic subluxation of the atlanto-axial joint that occurs after infection or inflammation in the otolaryngological area, primarily in children.Method: This report describes the clinical characteristics of an extremely rare case of adult-onset Grisel's syndrome.Result: A 77-year-old woman presented with neck and bilateral shoulder pain and stiffness. Her temperature was 37.6 °C. Blood testing revealed a mildly elevated inflammatory response, although blood cultures were negative. Computed tomography (CT) showed atlanto-axial subluxation and joint destruction. T2-weighted magnetic resonance imaging (MRI) displayed high signals in the soft tissues in the anterior space of the atlas and axis, posterior wall of the pharynx, and interspinous ligament, indicating spinal cord compression at the C1 level. Differential diagnoses of inflammation and diseases causing atlanto-axial subluxation included rheumatoid arthritis, amyloidosis, pyogenic spondylitis due to posterior pharyngeal abscess, and crowned dens syndrome. After the systematic elimination of each condition, we considered Grisel's syndrome and began non-surgical treatment with intravenous antibiotics and a Philadelphia neck collar. Her inflammatory response and neck pain gradually decreased. Six months later, there was no progression of instability. She was able to walk unaided and live normally with the use of a neck collar as needed.Conclusion: Grisel's syndrome occurs predominantly in children, but can also afflict adults. Since early diagnosis and treatment can improve symptoms in some cases and prevent progressive atlanto-axial instability, prompt evaluation of the atlanto-axial joint using CT or MRI is advised in patients with neck pain and limited range of motion.
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Schwannoma is the most common tumor of the peripheral nerve sheath. However, there have been few reports on schwannoma of the posterior tibial nerve causing tarsal tunnel syndrome. We report on a 60-year-old man with tarsal tunnel syndrome caused by a schwannoma of the posterior tibial nerve, which was first diagnosed as a ganglion cyst. After enucleation of this tumor, the patient was asymptomatic and had no related sequelae except for minor numbness in the plantar aspects of his digits. Although schwannoma of the posterior tibial nerve is rare, it should be considered even if a ganglion is clinically suspected.