Clinical Outcomes of Total Wrist Arthroplasty in Patients With Rheumatoid Arthritis: Minimum 10-Year Follow-Up Study.

PURPOSE: We developed a semiconstrained total wrist prosthesis that was used in a series of patients with rheumatoid arthritis. We previously reported favorable clinical outcomes for up to 5 years after surgery; however, the longer-term outcomes remain unclear. The objective of this study was to evaluate the clinical outcomes of this wrist prosthesis for the treatment of severe wrist rheumatoid arthritis during a minimum 10 years of follow-up. METHODS: From 2010 through 2012, total wrist arthroplasty using the semiconstrained total wrist arthroplasty device was performed in 20 wrists in 20 patients with rheumatoid arthritis (five men and 15 women). The mean patient age was 64 years (range, 50-84 years). Preoperative radiographs showed Larsen grade IV changes in 16 wrists and grade V changes in four wrists. Patients were evaluated clinically and radiologically before surgery, 5 years after surgery, and 10 years or more after surgery. Evaluated parameters were the visual analog scale for pain, range of motion, Figgie score, and Disabilities of the Arm, Shoulder, and Hand score. RESULTS: The minimum 10-year follow-up clinical results (mean, 11.3 years) were available for all 14 surviving patients (three men and 11 women). Significant improvements in the mean visual analog scale for pain, Figgie score, and Disabilities of the Arm, Shoulder, and Hand score, compared with those before surgery, were maintained from 5 years after surgery to the final follow-up. The mean wrist flexion angle tended to slightly decrease at 5 years after surgery compared with that before surgery but remained similar from 5 years after surgery to the final follow-up. The increase in the mean wrist extension angle, compared with that before surgery, was maintained from 5 years after surgery to the final follow-up. Radiographic evaluation had already revealed implant loosening in five of the 19 wrists at 5 years after surgery, but there were no new cases of component loosening identified at the final follow-up. CONCLUSIONS: Total wrist arthroplasty using the semiconstrained arthroplasty system achieves favorable clinical outcomes with no serious complications requiring revision for 10 years after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Effect of urgent surgery within 8 hours compared to surgery between 8 and 24 hours on perioperative complications and neurological prognosis in patients older than 70 years with cervical spinal cord injury: a propensity score-matched analysis.

OBJECTIVE: This study aimed to investigate the effect of surgery within 8 hours on perioperative complications and neurological prognosis in older patients with cervical spinal cord injury by using a propensity score-matched analysis. METHODS: The authors included 87 consecutive patients older than 70 years who had cervical spinal cord injury and who had undergone posterior decompression and fusion surgery within 24 hours of injury. The patients were divided into two groups based on the time from injury to surgery: surgery within 8 hours (group 8 hours) and between 8 and 24 hours (group 8-24 hours). Following the preliminary study, the authors established a 1:1 matched model using propensity scores to adjust for baseline characteristics and neurological status on admission. Perioperative complication rates and neurological outcomes at discharge were compared between the two groups. RESULTS: Preliminary analysis of 87 prematched patients (39 in group 8 hours and 48 in group 8-24 hours) revealed that the motor index score (MIS) on admission was lower for lower extremities (12.3 ± 15.5 vs 20.0 ± 18.6, respectively; p = 0.048), and total extremities (26.7 ± 27.1 vs 40.2 ± 30.6, respectively; p = 0.035) in group 8 hours. In terms of perioperative complications, group 8 hours had significantly higher rates of cardiopulmonary dysfunction (46.2% vs 25.0%, respectively; p = 0.039). MIS improvement (the difference in scores between admission and discharge) was greater in group 8 hours for lower extremities (15.8 ± 12.6 vs 9.0 ± 10.5, respectively; p = 0.009) and total extremities (29.4 ± 21.7 vs 18.7 ± 17.7, respectively; p = 0.016). Using a 1:1 propensity score-matched analysis, 29 patient pairs from group 8 hours and group 8-24 hours were selected. There were no significant differences in baseline characteristics, neurological status on admission, and perioperative complications between the two groups, including cardiopulmonary dysfunction. Even after matching, MIS improvement was significantly greater in group 8 hours for upper extremities (13.0 ± 10.9 vs 7.8 ± 8.3, respectively; p = 0.045), lower extremities (14.8 ± 12.7 vs 8.3 ± 11.0, respectively; p = 0.044) and total extremities (27.8 ± 21.0 vs 16.0 ± 17.5, respectively; p = 0.026). CONCLUSIONS: Results of the comparison after matching demonstrated that urgent surgery within 8 hours did not increase the perioperative complication rate and significantly improved the MIS, suggesting that surgery within 8 hours may be efficient, even in older patients.

Epidemic Preventive Management during the Coronavirus Disease 2019 Pandemic Is a Risk Factor for Delirium after Spinal Cord Injury Surgery.

Introduction: Epidemic preventive management during the coronavirus disease 2019 (COVID-19) pandemic may have negatively impacted perioperative outcomes in patients with traumatic spinal cord injury (SCI). However, little is known about the relationship between epidemic preventive management and delirium after traumatic SCI. Here, we clarified the predictors of delirium after SCI surgery. Methods: We retrospectively analyzed 231 patients (mean age, 66 years) who underwent SCI surgery between 2017 and 2021. Patients were categorized into the delirium and non-delirium groups. Preoperative characteristics and laboratory data related to the occurrence of delirium were assessed. During the study period, we continued early surgical intervention. However, early rehabilitation intervention was not performed in the hospital rehabilitation room from May 2020 due to epidemic preventive management, which involved performing rehabilitation on the bed for 8 days postoperatively. Results: Postoperatively, 33 (14.3%) patients experienced delirium. Univariate analysis showed that age (p<0.01), presence of a psychiatric disorder (p<0.05), dementia (p<0.05), serum albumin (p<0.05) and hemoglobin (p<0.01) levels, American Society of Anesthesiologists classification score (p<0.05), and treatment during the COVID-19 pandemic (p<0.01) differed significantly in the delirium and non-delirium groups. Multivariate logistic regression analysis showed that an age ≥73 years (odds ratio [OR], 15.78; 95% confidence interval [CI], 4.54-54.80; p<0.01), treatment during the COVID-19 pandemic (OR, 3.85; 95% CI, 1.61-9.22; p<0.01), and psychiatric disorder (OR, 29.38; 95% CI, 5.63-153.43; p<0.01) were associated with delirium. Conclusions: Our comprehensive preventive management during the COVID-19 pandemic was identified as one of the risk factors for delirium after SCI surgery. Patients with preventive management should be cautioned regarding the risk of delirium.

The Impact of Diffuse Idiopathic Skeletal Hyperostosis on Nutritional Status, Neurological Outcome, and Perioperative Complications in Patients with Cervical Spinal Cord Injury.

This retrospective study aimed to investigate the characteristics of patients with cervical spinal cord injuries (CSCI) with diffuse idiopathic skeletal hyperostosis (DISH). We included 153 consecutive patients with CSCI who underwent posterior decompression and fusion surgery. The patients were divided into two groups based on the presence of DISH. Patient characteristics, neurological status on admission, nutritional status, perioperative laboratory variables, complications, neurological outcomes at discharge, and medical costs were compared between the groups. The DISH group (n = 24) had significantly older patients (72.1 vs. 65.9, p = 0.036), more patients with low-impact trauma (62.5% vs. 34.1%, p = 0.009), and a lower preoperative prognostic nutritional index on admission (39.8 vs. 42.5, p = 0.014) than the non-DISH group (n =129). Patients with DISH had significantly higher rates of ventilator management (16.7% vs. 3.1%, p = 0.022) and pneumonia (29.2% vs. 8.5%, p = 0.010). There was no significant difference in medical costs and neurological outcomes on discharge. Patients with CSCI and DISH were older, had poor nutritional status, and were prone to postoperative respiratory complications, while no differences were found between the neurological outcomes of patients with CSCI with and without DISH.

Incidence and Risk Factors for Pneumonia in the Chronic Phase of Cervical Spinal Cord Injury with Complete Motor Paralysis.

Introduction: Pneumonia is one of the leading causes of acute- and chronic-phase mortality in patients with cervical spinal cord injury (CSCI) with quadriplegia. The risk factors for chronic-phase pneumonia recurrence in CSCI are still unknown. This study aimed to investigate the incidence of pneumonia in the chronic phase after injury and to identify its risk factors. Methods: This retrospective clinical observational study included patients with CSCI with American Spinal Injury Association Impairment Scale grades of A or B admitted to our center within 72 h of CSCI injury who started treatment and were available for follow-up for at least 90 days. The patients were assessed for incidences of pneumonia and its associations with clinical characteristics, including risk factors at the time of injury. Patients in whom pneumonia developed within 30 days postadmission and those after 30 days of hospitalization were comparatively examined using univariate and multivariate analyses. Results: Pneumonia occurred in 36% of the 69 enrolled patients throughout the study period and in 20% of all patients after 30 days of hospitalization. Multivariate analysis of risk factors for pneumonia showed that atelectasis (adjusted OR [aOR], 95% confidence interval [CI]: 4.9, 1.2-20.0), enteral feeding (aOR [95% CI]: 13.3 [3.0-58.9]), mechanical ventilation (aOR [95% CI]: 4.0 [1.0-15.0]), and tracheotomy (aOR [95% CI]: 14.6 [2.3-94.6]) within 30 days of admission were significantly associated with the occurrence of pneumonia even after 30 days of hospitalization. Conclusions: The risk factors for developing pneumonia in the chronic phase were atelectasis, enteral feeding, mechanical ventilation, and tracheotomy within 30 days of hospitalization. This study suggests that treatment of atelectasis, long-term respiratory muscle rehabilitation, and training to improve swallowing function are essential to prevent the recurrence of pneumonia after 30 days of hospitalization.

Complications Associated with Preventive Management to Reduce the Risk of COVID-19 Spread After Surgery for Spinal Cord Injury.

BACKGROUND: Preventive management to reduce the risk of coronavirus disease-2019 (COVID-19) spread led to delays in active rehabilitation, which may have negatively impacted the outcomes of patients with traumatic spinal cord injury (SCI). Therefore, the aim of this study was to clarify the influence of preventive management on the rate of perioperative complications after surgical treatment for SCI. METHODS: This single-center retrospective study examined the cases of 175 patients who had SCI surgery between 2017 and 2021. We could not continue early rehabilitation interventions starting on April 30, 2020, because of our preventive management to reduce the risk of COVID-19 spread. Using a propensity score-matched model, we adjusted for age, sex, American Spinal Injury Association impairment scale score at admission, and risk factors for perioperative complications described in previous studies. Perioperative complication rates were compared between the COVID-19 pandemic and prepandemic groups. RESULTS: Of the 175 patients, 48 (the pandemic group) received preventive management. The preliminary analysis revealed significant differences between the unmatched pandemic and prepandemic groups with respect to age (75.0 versus 71.2 years, respectively; p = 0.024) and intraoperative estimated blood loss (152 versus 227 mL; p = 0.013). The pandemic group showed significant delays in visiting the rehabilitation room compared with the prepandemic group (10 versus 4 days from hospital admission; p < 0.001). There were significant differences between the pandemic and prepandemic groups with respect to the rates of pneumonia (31% versus 16%; p = 0.022), cardiopulmonary dysfunction (38% versus 18%; p = 0.007), and delirium (33% versus 13%; p = 0.003). With a propensity score-matched analysis (C-statistic = 0.90), 30 patients in the pandemic group and 60 patients in the prepandemic group were automatically selected. There were significant differences between the matched pandemic and prepandemic groups with respect to the rates of cardiopulmonary dysfunction (47% versus 23%; p = 0.024) and deep venous thrombosis (60% versus 35%; p = 0.028). CONCLUSIONS: Even with early surgical intervention, late mobilization and delays in active rehabilitation during the COVID-19 pandemic increased perioperative complications after SCI surgery. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Efficacy of a machine learning-based approach in predicting neurological prognosis of cervical spinal cord injury patients following urgent surgery within 24 h after injury.

We aimed to develop a machine learning (ML) model for predicting the neurological outcomes of cervical spinal cord injury (CSCI). We retrospectively analyzed 135 patients with CSCI who underwent surgery within 24 h after injury. Patients were assessed with the American Spinal Injury Association Impairment Scale (AIS; grades A to E) 6 months after injury. A total of 34 features extracted from demographic variables, surgical factors, laboratory variables, neurological status, and radiological findings were analyzed. The ML model was created using Light GBM, XGBoost, and CatBoost. We evaluated Shapley Additive Explanations (SHAP) values to determine the variables that contributed most to the prediction models. We constructed multiclass prediction models for the five AIS grades and binary classification models to predict more than one-grade improvement in AIS 6 months after injury. Of the ML models used, CatBoost showed the highest accuracy (0.800) for the prediction of AIS grade and the highest AUC (0.90) for predicting improvement in AIS. AIS grade at admission, intramedullary hemorrhage, longitudinal extent of intramedullary T2 hyperintensity, and HbA1c were identified as important features for these prediction models. The ML models successfully predicted neurological outcomes 6 months after injury following urgent surgery in patients with CSCI.

Clinical and radiological outcomes of posterior cervical decompression and fusion for severe cervical compressive-extension injury: A case series.

BACKGROUND: Although severe cervical compressive-extension (CE) injuries are usually repaired using a combined anterior-posterior approach, the repair is possible using a posterior approach alone with reliable anchors. This study aimed to present the outcomes and imaging analysis results of posterior cervical decompression and fusion (PCDF) for severe CE injuries. METHODS: We retrospectively reviewed 16 patients who underwent PCDF surgery for severe CE injuries (>50% subluxation) between January 2012 and December 2018. All patients completed 1-year follow-up, and their mean age at the time of surgery was 63.5 years. American Spinal Injury Association Impairment Scale (AIS) grade, kyphotic angle of lower vertebra (KALV), and anterior defect area of lower vertebra (ADLV) were assessed preoperatively. RESULTS: Of 16 patients, nine patients improved at the final follow-up, and eight patients could walk with or without assistance. All patients achieved bone union postoperatively, but four patients showed progression of correction loss of ≥10°. Therefore, patients were divided into two groups: NL group with correction loss of <10°; L group with correction loss of ≥10°. All patients in L group showed KALV of ≥15°, while 10 of 12 patients in NL group showed KALV of <15°. Furthermore, all patients in L group showed ADLV of ≥50%, whereas all patients in NL group showed ADLV of <50%. CONCLUSIONS: PCDF is feasible and a favorable procedure for severe CE injuries that require early reduction and cervical spinal stabilization. However, in the cases of advanced destruction of the anterior vertebra, loss of correction after PCDF might occur postoperatively.

The Impact of Carpal Tunnel Release on Two-Point Discrimination, Quick Disabilities of Arm, Shoulder and Hand Score and Distal Motor Latency - A Multi-centre Prospective Study.

Background: The authors conducted a prospective, multi-centre study to assess the impact of carpal tunnel release (CTR) on Two-Point Discrimination (2-PD), Quick Disabilities of Arm, Shoulder and Hand Score (Q-DASH), and Distal Motor Latency (DL). The primary aim was to determine the change in outcome measurements (2-PD, Q-DASH and DL) preoperatively and postoperatively at 6 months and 1 year. The secondary aims of the study were to determine whether the postoperative outcomes were different at the 6-month and 1-year follow-up and if there was difference in outcomes based on the preoperative severity of carpal tunnel syndrome (CTS). Methods: A total of 205 hands in 171 patients underwent CTR at five hospitals over a 2-year period. A total of 110 hands in 94 patients were followed-up and analysed. The 2-PD, Q-DASH and DL were measured for all patients preoperatively and at 6 months and 1 year postoperatively. Patients were divided into two groups 'mild' and 'severe' based on pre-operative DL score (mild ≤ 8.1 msec). The change in preoperative and postoperative 2-PD, Q-DASH and DL values were compared. The change in pre-operative and post-operative 2-PD and Q-DASH values were also compared between the 'mild' and 'severe' groups. Results: The 2-PD, Q-DASH and DL showed significant improvement at 6-month and 1-year follow-ups compared to pre-operative values. However, there were no significant differences in all three parameters between the 6-month and 1-year measurements. There was significant improvement in preoperative and postoperative 2-PD and Q-DASH scores between the mild and severe groups. Conclusions: CTR is an effective treatment for patients with CTS with significant improvement in all three outcome parameters (2-PD, Q-DASH and DL). The improvement in outcome plateaus at 6 months and additional follow-up may not be useful. Level of Evidence: Level II (Therapeutic).

Safety of early posterior fusion surgery without endovascular embolization for asymptomatic vertebral artery occlusion associated with cervical spine trauma.

PURPOSE: Vertebral artery occlusion (VAO) is an increasingly recognized complication of cervical spine trauma. However, the management strategy of VAO remains heavily debated. Therefore, the aim of this retrospective study was to investigate the safety of early fusion surgery for traumatic VAO. METHODS: This study included a total of 241 patients (average age 64.7 years; 201 men) who underwent early surgical treatment for acute cervical spine injury between 2012 and 2019. The incidence of VAO, cerebral infarction rates, the recanalization rates, and cerebral thromboembolism after recanalization were retrospectively analyzed. RESULTS: VAO occurred in 22 patients (9.1%). Of the 22 patients with VAO, radiographic cerebral infarction was detected in 4 patients (21.1%) at initial evaluation, including 1 symptomatic medullar infarction (4.5%) and 3 asymptomatic cerebrum infarctions. A patient who experienced right medullar infarction showed no progression of the neurologic damage. Follow-up imaging revealed that the VAOs of 9 patients (40.9%) were recanalized, and the recanalization did not correlate with clinical adverse outcomes. The arteries of the remaining 13 (59.1%) patients remained occluded and clinically silent until the final follow-up (mean final follow-up 33.0 months). CONCLUSION: Despite the lack of a concurrent control group with preoperative antiplatelet therapy or endovascular embolization for VAO, our results showed low symptomatic stroke rate (4.5%), high recanalization rate (40.9%), and low mortality rate (0%). Therefore, we believe that the indication for early stabilization surgery as management strategy of asymptomatic VAO might be one of the safe and effective treatment options for prevention of symptomatic cerebral infarction.

Rare case of real-time observation of paralytic deterioration after cervical dislocation in the hyperacute phase.

BACKGROUND: There have been no prior reports of real-time detailed records leading to complete quadriplegia immediately after fracture dislocation in high-energy trauma. Here, we report a case of cervical dislocation in which the deterioration to complete motor paralysis (modified Frankel B1) and complete recovery (Frankel E) could be monitored in real time after reduction in the hyperacute phase. CASE PRESENTATION: A 65-year-old man was involved in a car accident and sustained a dislocation at the C5/6 level (Allen-Ferguson classification: distractive flexion injury stage IV). His paralysis gradually deteriorated from Frankel D to C 2 hours after the injury and from Frankl C to B 5 hours after the injury. His final neurological status immediately before reduction was Frankel B1 (complete motor paralysis with sensation only in the perianal region). Reduction was completed within 6 h and 5 min after injury, and spinal fusion was subsequently performed. The patient exhibited rapid motor recovery immediately after surgery, and was able to walk independently on postoperative day 14. CONCLUSIONS: This case suggests that there is a mixture of cases in which the spinal cord has not been catastrophically damaged, even if the patient has complete motor paralysis. Prompt reduction has the potential to improve neurological function in such cases.

Two case reports of 'locked spondyloptosis': the most severe traumatic cervical spondyloptosis with locked spinous process and vertebral arch into the spinal canal.

INTRODUCTION: Traumatic cervical spondyloptosis, including compressive-extension stage 5 of Allen's classification of cervical spine injuries, is commonly observed; however, cases involving locked spinous process and vertebral arch into the spinal canal are extremely rare. CASE PRESENTATION: We present two individuals with spondyloptosis of C7 with locked spinous process of C6 and the vertebral arch into the spinal canal. Closed reduction was unable to be performed due to rigid locking of the cervical spine in the first case, whereas preoperative closed reduction was achieved with mild traction in a prone position after general anaesthesia in the second case. These two individuals underwent spinal fusion via a posterior approach after open or closed reduction. Six months after surgery, both individuals exhibited significant neurological recovery and acquired a stable gait. DISCUSSION: To the best of our knowledge, this is the first report of traumatic 'locked spondyloptosis' of the spinous process and vertebral arch into the spinal canal. Although high-grade compressive-extension injuries are usually repaired using a combined anterior-posterior approach, repair is possible with a posterior approach alone with reliable anchors, such as pedicle screws or multiple lateral mass screws. Urgent open reduction may be required for locked spondyloptosis when closed reduction is invalid due to rigid locking of the cervical spine.

A Minimum 5-Year Longitudinal Study of a New Total Wrist Arthroplasty in Patients With Rheumatoid Arthritis.

PURPOSE: To evaluate the longitudinal clinical outcomes using a new semiconstrained wrist prosthesis for the treatment of severe rheumatoid arthritis of the wrist. METHODS: Twenty patients with rheumatoid arthritis (20 wrists) underwent total wrist arthroplasty with the prosthesis in a clinical trial. The preoperative Larsen classification was grade IV in 16 wrists and grade V in 4 wrists. Assessments were performed before surgery, 1.5 years after surgery, and at final follow-up (≥ 5 years after surgery) using the visual analog scale for pain, Figgie wrist score, Japanese version of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and plain radiographs. RESULTS: At final follow-up, no patient had wrist pain. The preoperative flexion-extension arc at final follow-up was similar to the preoperative range. The mean 1.5-year postoperative Figgie score was significantly improved and was unchanged at final follow-up. The DASH score significantly improved from before surgery to 1.5 years after surgery; the DASH score was improved further at final follow-up, but not significantly. Five of the 19 wrists evaluated had radiographic findings indicating carpal component loosening at final follow-up; however, all patients with the loosening were asymptomatic and had not undergone revision surgery. CONCLUSIONS: Total wrist arthroplasty using this wrist prosthesis leads to favorable clinical outcomes regarding pain relief and retained range of wrist motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Time Course of Respiratory Dysfunction and Motor Paralysis for 12 Weeks in Cervical Spinal Cord Injury without Bone Injury.

INTRODUCTION: Cervical spinal cord injury without bone injury (SCIWOBI) is a common cervical injury in the elderly population and is most likely to occur at the C3/C4 level. Respiratory dysfunction (RD) related to the damage of the spinal respiratory center, which is close to the C4 segment, is one of the greatest obstacles in improving the activities of daily living of patients with severe paralysis. We evaluated the time course of RD and motor function in cervical SCIWOBI to identify effective medical strategies. METHODS: We followed 54 patients (49 men, 5 women; mean age: 65 years old) who were treated for SCIWOBI at our medical center from 2011 to 2014. The patients were evaluated within 72 hours of injury and were monitored for at least 12 weeks. All patients began respiratory-muscle training the day after admission regardless of whether they were treated conservatively or surgically. The percent vital capacity (%VC), forced expiratory volume (FEV) in one second/forced vital capacity ratio (FEV 1.0%), and American Spinal Injury Association motor score (MS) were recorded at admission and again at weeks 4 and 12. We calculated the %VC rate of change and the MS improvement rate over the entire period. RESULTS: Fifty patients (92.6%) had restrictive ventilatory impairment at admission. The %VC correlated with the upper- and lower-limb MSs at admission, and the %VC and upper- and lower-limb MSs had improved by weeks 4 and 12 after the injury. The %VC rate of change was significantly correlated with the rate of improvement in lower-limb MS throughout the entire period. CONCLUSIONS: Lung capacity decreased in SCIWOBI owing to respiratory-muscle paralysis and upper- and lower-limb motor paralyses. Lung capacity improved as the lower limbs recovered their motor function. Respiratory rehabilitation should be continued for at least 12 weeks after SCIWOBI.

Early surgical intervention may facilitate recovery of cervical spinal cord injury in DISH.

STUDY DESIGN: A retrospective study of consecutive surgically managed cases of cervical spinal fractures and diffuse idiopathic skeletal hyperostosis (DISH) at our hospital from October 2006 to April 2016. SUMMARY OF BACKGROUND DATA: Prognostic factors have not been determined for cervical fractures in DISH. OBJECTIVES: To assess demographics, surgical techniques, and complications in cervical spinal cord injury with DISH and to evaluate factors affecting neurological prognosis. METHODS: Patients' medical records and radiographs were reviewed and analyzed for demographics, injury characteristics, surgical outcomes, perioperative complications, additional surgeries, and neurological prognosis. Neurological status was assessed by the American Spinal Injury Association (ASIA) grade at admission and discharge. RESULTS: Of 38 patients (mean age 71.9 ± 8.8), 20 had type 1 fractures (through the disc space), 8 had type 2 (through the vertebral body), and 10 had type 3 (through disc and vertebral body). ASIA grades at admission included 14 ASIA-A, 4 ASIA-B, 7 ASIA-C, 8 ASIA-D, and 5 ASIA-E. All patients underwent posterior fusion with an average of 4.5 ± 2.5 instrumented vertebrae (range, 2-7) and six patients required secondary halo-vest fixation. Of 14 ASIA-A patients, 12 developed serious postsurgical pulmonary complications and 4 of these died within 6 months of surgery. Of the 38 patients, 13 improved more than one grade after treatment, 24 did not improve, and 1 deteriorated. In the 18 ASIA-A/B cases (complete motor paralysis), neither fracture type nor injury mechanism (e.g. a ground-level fall or high-energy trauma) correlated with neurological prognosis, but a time of 8 h or less from injury to surgery correlated significantly with an improvement from ASIA A/B to C/D ( p < 0.01, Pearson's χ2 test). CONCLUSION: Patients with complete motor paralysis after a cervical fracture with DISH may recover to partial paralysis if surgically treated within 8 h of injury.

Rapidly progressive cervical myelopathy had a high risk of developing deep venous thrombosis: a prospective observational study in 289 cases with degenerative cervical spine disease.

STUDY DESIGN: A prospective observational study. OBJECTIVES: To determine the incidence of deep venous thrombosis (DVT) and to evaluate the risk factors for DVT development associated with degenerative cervical spine disease. SETTING: Hokkaido Spinal Cord Injury Center, Japan. METHODS: Between April 2008 and March 2015, patients with degenerative cervical spine disease, such as compressive myelopathy or radiculopathy, who underwent surgical treatment were prospectively assessed. Leg vein ultrasonography and D-dimer tests were performed preoperatively and at 4 days after surgery. All patients received treatment with intermittent pneumatic compression and elastic stockings for primary DVT prophylaxis. No anticoagulation medications were used for DVT prophylaxis. RESULTS: A total of 289 patients (203 males, 86 females; median age: 67 years (interquartile range, 58-76)) were included. Nine patients (3.1%) exhibited DVT during the perioperative period. All 9 cases were women who had distal DVT. The incidences of preoperative and postoperative DVT were 1.1% and 2.1%, respectively. The univariate analysis showed that statistically significant risk factors for perioperative DVT included female gender (P < 0.01), advanced age (P = 0.04), a low Japanese Orthopaedic Association score (P = 0.03), rapidly progressive myelopathy (P < 0.01), and inability to walk (P = 0.01). The multivariate analysis showed that rapidly progressive myelopathy (P = 0.04) was the most important risk factor. CONCLUSION: Female gender and rapidly progressive myelopathy are high-risk factors that predict the development of DVT during the perioperative period of cervical spine surgery. This result indicates that screening and treatment for DVT are needed in such high-risk patients.

Two-stage corrective surgery for severe rigid cervical kyphotic deformity with unilateral vertebral artery occlusion after old blunt trauma: a case report.

INTRODUCTION: There are considerable risks for vertebral artery (VA) injury in case of corrective surgery for a severe and rigid cervical kyphotic deformity. This case report describes a rare case of surgical management for pre-existing traumatic rigid cervical kyphosis associated with unilateral VA occlusion. CASE PRESENTATION: A 73-year-old male fell down and injured his neck. He was referred to our hospital 10 months after injury because his degree of head drop progressed gradually to a chin-on-chest position such that he could not look straight forward. On plain X-ray, the C2-7 angles in the neutral, flexion, and extension positions were 61°, 71°, and 50°, respectively. CT revealed a collapse of the C5 vertebral body and bone fusion between C4 and C5 in the anterior vertebrae, and unilateral VA occlusion was confirmed by angiography. Two-stage surgery was planned to correct the kyphosis. In the first stage, anterior release of the C4/5 bone-spur fusion and dissection of the intervertebral disk were performed. After release, angiography confirmed neither occlusion nor rupture of the VA. In the second stage, anterior and posterior fixation was performed at correcting position while maintaining slight kyphosis in order to avoid excessive distortion of the VA. The postoperative C2-7 kyphosis angle improved to 16° without any VA injury, and the patient could look forward easily. DISCUSSION: The degree of correction as well as risk management of VAs should be considered carefully during corrective surgery for severe and rigid cervical kyphosis, especially with unilateral VA occlusion.

Awareness of traumatic occult lateral mass fracture of the cervical spine triggered by the presence of unilateral vertebral artery occlusion: a case report.

INTRODUCTION: We present an unusual case of traumatic occult lateral mass fracture of the cervical spine with unilateral occlusion of the vertebral artery (VA), that was missed by plain X-ray and magnetic resonance imaging (MRI), but identified by computed tomography (CT) after suspecting high-energy trauma as the underlying cause. CASE PRESENTATION: A 67-year-old male was injured in a car accident and came to our institute on foot 4 days after injury with complaints of neck pain and numbness in the right hand. Although, no specific bone injury was visible on plain X-ray, the absence of flow voids in the right VA was confirmed on axial T2-weighted MRI. We suspected high-energy trauma of the cervical spine at that point and performed CT for a more detailed assessment. Consequently, a fracture was detected in the right lateral mass of C6 and we speculated that spontaneous reduction of the fracture-dislocation had occurred. One-stage surgery with posterior fixation was subsequently performed for instability. The patient's preoperative symptoms were improved and neither recanalization of the occlusion nor another VA occlusion was observed after surgery. DISCUSSION: VA injury occurs frequently as a complication of blunt cervical spine trauma. In the present case, however, the lateral mass fracture was not seen on MRI and missed until the unilateral VA injury was detected. When high-energy trauma of the cervical spine is suspected, it is important to evaluate damage to the spinal cord, bone, soft-tissue, and VA by MRI and CT.

Postoperative Infection Related with the Total Elbow Arthroplasty (Kudo's Prosthesis) in Rheumatoid Arthritis.

BACKGROUND: Total Elbow Arthroplasty (TEA) for the rheumatoid arthritis (RA) has been popularized since 1980s. The outcomes of TEA using any type of implant design for RA has been satisfactory. On the other hand, many orthopedicians experience several postoperative complications. Among them, postoperative infection has still being the most troublesome and difficult to treat. This study is to clarify the causes of postoperative infection of TEA using Kudo's prosthesis for RA and discuss how to manage and prevent infection. METHODS: 421 TEAs were performed for 405 cases with RA at the authors' institute during the period between 1982 and 2007. They were followed up for 1~25 years (Av. 12.3 years). The authors examined pain, the range of motion, roentgenograms and complications postoperatively. We were able to start treatment within 4 weeks after occurrence of infection. For surgical management of infected TEAs, debridement of the synovium and removal of the prosthesis with loosening were performed for all cases. In addition, all cases have been regularly and strictly followed-up with the elbow protector to prevent recurrence of infection since 2008. RESULTS: There were 98 TEAs with the postoperative complications (23.3%). Eight out of 98 TEAs were infected (1.9%). Five of eight infected TEAs were primarily at the surgical scar site infection (SSSI) (60%), unknown causes in two, hematogenous course in 1. It's obvious that surgical scar site infection (SSSI) was the leading cause of postoperative infection in this study. Thus, the authors made the elbow proctor to avoid injuries of the skin around surgical scar site (SSS). Since 2008, all of the TEAs and revised TEAs have been applied with this protector. CONCLUSIONS: The authors reported 8 infected TEAs: 5 cases were revised, 2 with the brace, 1 had above the elbow amputated. The regular and meticulous follow up and application of the elbow protector were useful to prevent infection of post-TEAs using Kudo's prosthesis in RA. Since 2008, there have been no infection of post TEAs and revised TEAs.

Dural penetration caused by a vertebral bone fragment in a lumbar burst fracture: a case report.

INTRODUCTION: This case report describes an unusual case of lumbar burst fracture in which a bone fragment from the vertebral body penetrated into the dorsal dura through the ventral dura mater, requiring bone fragment extraction via an intradural approach. CASE PRESENTATION: A 23-year-old male involved in a motor vehicle accident was admitted to our hospital complaining of right leg paresis and bladder-bowel disorder. Computed tomography (CT) revealed an L5 burst fracture of type B by the Denis classification scheme, with a bone fragment from the vertebral body that had perforated the ventral aspect of the dura mater and penetrated dorsally. We abandoned attempts to extract the bone fragment via an epidural approach and instead resected the fragment via an intradural approach with a dorsal dural incision. We corrected L4/5 kyphosis as possible and performed L4/5 posterolateral fusion. The patient's leg paralysis and bladder-bowel disorder were relieved, and he was discharged 2 months after the surgery with the ability to walk without crutches. DISCUSSION: When bone fragments penetrate the dura mater, their extraction must be performed with particular care. For cases in which the dura mater cannot be pulled apart, the removal of bone fragments using an intradural approach is appropriate.