Effect of pre-operative HbA1c and blood glucose level on the surgical site infection after lumbar instrumentation surgery.

BACKGROUND: This study aims to investigate the effect of pre-operative hemoglobin A1c (HbA1c) and pre-operative blood glucose control on the rate of surgical site infection (SSI) after posterior lumbar instrumentation surgery in diabetes mellitus (DM) patients. METHODS: A total of 1046 patients who had undergone posterior lumbar instrumentation surgery were reviewed. Based on pre-operative HbA1c, patients were divided into three groups: non-DM group, low HbA1c group (HbA1c < 7.0 % in DM) and high HbA1c group (≥7.0). As well, based on the status of blood glucose control in DM patients immediately before surgery, patients were divided into two groups: good control group (post-prandial blood glucose [PBG] < 200 mg/dl) and poor control group (≥200). The rate of SSI was compared among these groups. RESULTS: SSI occurred in 1.9 % in non-DM group, 2.4 % in low HbA1c group, and 9.3 % in high HbA1c group. Compared with non-DM group, high HbA1c group had significantly higher rate of SSI (p = 0.001). There was not statistically different between non-DM and low HbA1c groups (p = 0.550). SSI occurred in 2.2 % in good control group, and 10.2 % in poor control group. The rate of SSI was significantly lower in good control group (p = 0.013). CONCLUSION: This study showed that the rate of SSI after posterior lumbar instrumentation surgery tend to be higher in DM patients with high HbA1c. However, the rate might be reduced to the same level as that of non-DM group by lowering PBG to <200 mg/dl immediately before surgery.

Posterior lumbar fusion surgery doesn't change sexual activities in patients with lumbar degenerative disease: an observational study.

BACKGROUND: There are few studies about sexual function in the patient with posterior lumbar spinal fusion for degenerative lumbar disease. The aim of this study is to investigate sexual activities in patients with lumbar degenerative disease before and after lumbar fusion surgery. METHODS: We recruited 35 patients who underwent lumbar spinal fusion at the age of 55 years or younger. They were 17 men and 18 women with a mean age of 47.4 years. After informed consent, the patients were asked to complete anonymous questionnaire concerning sexual desire, activity, and satisfaction before and after surgery. RESULTS: In the presick period, 69% of the patients had sexual desire, and 79% achieved satisfaction during sexual activity. Lumbar degenerative disease decreased sexual desire and frequency of sexual activity in 40%, and 74% respectively. Before surgery, satisfaction in sexual activities decreased in 53%, and 55% of the patients felt discomfort during sexual activity. Adjustment in sexual position was required in 44% of man and 54% of woman. After surgery, Sexual desire, frequency of sexual activity and satisfaction did not regain after surgery in 94%, 93% and 92%, respectively. Those who did not feel discomfort after surgery was significantly lower VAS in both low back pain and leg pain than the patients felt discomfort (low back pain; p = 0.024, leg pain; p = 0.046). CONCLUSION: This study demonstrated that lumbar degenerative diseases decreased sexual desire, frequency of sexual activity and satisfaction, and little of the patients regained their sexual activities after posterior lumbar fusion surgery in the middle-aged patients.

Patterns of Vertebral Bone Marrow Edema in the Normal Healing Process of Lumbar Interbody Fusion: Baseline Data for Diagnosis of Pathological Events.

STUDY DESIGN: Retrospective investigation using a prospectively collected database. OBJECTIVE: To examine the appearance and characteristics of vertebral bone marrow edema (BME) in the normal healing of lumbar interbody fusion. SUMMARY OF BACKGROUND DATA: Although BME in pathological spinal conditions has been well-documented, the patterns and characteristics of BME in the normal healing process of spinal fusion remains unexplored. MATERIALS AND METHODS: We reviewed imaging from 225 patients with normal healing following posterior lumbar interbody fusion or transforaminal lumbar interbody fusion. BME was identified on magnetic resonance imaging at the third postoperative week and categorized with respect to its appearance, including assessment of area and extension within the relevant vertebrae. RESULTS: Three hundred eighty-nine of the 450 instrumented vertebrae (86.4%) displayed evidence BME. All instances of BME were associated with the area of contact with the endplate. The average extent of BME was 32.7±1.0%. BME within normal healing following interbody fusion could be categorized into four types: no edema (13.6%), anterior corner (36.6%), around-the-cage focal (48.0%), and diffuse (1.8%). Anterior corner BME was significantly associated with instances of single cage placement than in dual cages (42.6% vs. 24.7%, P =0.0002). Single cages had a significantly higher rate of BME than dual cages (92.0% vs. 75.3%, P <0.0001). The extent of BME was significantly greater in the single cage cohort (36.9% vs. 24.2% in dual cages, P <0.0001). CONCLUSIONS: This serves as the first study demonstrating the patterns of BME associated with normal healing following lumbar interbody fusion procedures. Anterior corner BME and around-the-cage focal BME were the most common patterns encountered, with diffuse BME a relatively rare pattern. These findings might contribute to the better differentiation of postoperative pathological events from normal healing following lumbar interbody fusion. LEVEL OF EVIDENCE: 4.

Characteristics of the Patients with Poor Clinical Outcomes After Symptomatic Postoperative Lumbar Epidural Hematoma.

OBJECTIVE: Symptomatic postoperative lumbar epidural hematoma (PLEH) may lead to poor outcomes even after evacuation. This study aimed to verify the short-term clinical outcomes after the evacuation of PLEH and to clarify the characteristics of the patients with poor postoperative outcomes. METHODS: Twenty-five patients (average age; 70.4 years) underwent PLEH evacuation after lumbar spine surgery. The mean follow-up period was 12.0 (range 3-37) months. Pre and postoperative Japanese Orthopedic Association scores and visual analog scale (VAS) of low back pain (LBP), leg pain, and leg numbness were retrospectively collected. The dural sac cross-sectional area at the most compressed level was measured on magnetic resonance imaging. The patients were classified into 2 groups: poor outcome group (P group) had less than 50% of Japanese Orthopedic Associationrecovery rate and good group (G group) with 50% or more recovery rate. RESULTS: The rate of delayed evacuation (over 24 hours of onset) was significantly higher in P group than in G group (P = 0.027). There was no significant difference in dural sac cross-sectional areabetween the 2 groups (P = 0.438). VAS of LBP, leg pain, and leg numbness in G group significantly improved postoperatively. Although VAS of LBP and leg pain in P group significantly improved postoperatively, there was no significant difference between the pre and postoperative VAS of leg numbness. CONCLUSIONS: Delayed evacuation of PLEH can lead to poor postoperative outcomes after lumbar spine surgery. Moreover, patients with poor outcomes remained with postoperative leg numbness. Early evacuation of symptomatic PLEH is key to avoid poor outcomes and persistent leg numbness.

Pre-existing adjacent level foraminal stenosis does not affect the outcome of a single level lumbar interbody fusion.

BACKGROUND: The aim of this study was to investigate whether or not pre-existing asymptomatic neuroforaminal stenosis adjacent to the fusion level develops adjacent segment disease (ASD) after single-level lumbar interbody fusion. SUMMARY AND BACKGROUND DATA: Risk factors of ASD after spinal fusion have been well investigated, but there have been few studies focused on the relationship between ASD and pre-existing asymptomatic neuroforaminal stenosis. METHODS: A total of 302 patients who had undergone a single-level lumbar interbody fusion were reviewed at a minimum of 2 year follow-up. They were 109 men and 193 women with a mean age of 68.8 years. Follow-up periods was averaged 53.5 months. ASD was defined as neurological deterioration related to adjacent segment pathologies which required an additional surgery. Based on the pathologies, patients were divided into three categories: ASD due to foraminal stenosis (ASD-FS), ASD due to central stenosis (ASD-CS), and ASD due to herniated disc (ASD-HD). Measured variables were age, gender, diagnosis, BMI, decompression procedures at adjacent segments, preoperative anterior/posterior slip, asymptomatic neuroforaminal stenosis, facet tropism, and postoperative spinopelvic parameters. RESULTS: Thirty-eight patients (12.6%) developed ASD. There were 15 patients with ASD-FS, 18 patients with ASD-CS, and five patients with ASD-HD. Lumbar lordosis (LL) and sacral slope (SS) were significantly smaller and pelvic tilt (PT) was significantly larger in ASD-FS. Asymptomatic neuroforaminal stenosis was detected preoperatively in 33.3% of the ASD-FS group, and 18.6% of non-ASD group; the incidence was not significantly different. CONCLUSIONS: Adjacent-level neuroforaminal stenosis was not a significant risk of ASD after single-level lumbar interbody fusion, and might not need to be fused if asymptomatic.

Perioperative Complications of Open Spine Surgery in Older Adults over 90 Years of Age.

Introduction: Despite perioperative risks in nonagenarian patients who undergo open spine surgery for degeneration disorder or spinal trauma being of great interest, the prevalence of complications in this group remains unclear. This study aims to examine the perioperative complications of open spine surgery in the elderly over 90 years of age. Methods: Preoperative and intraoperative characteristics including the American Society of Anesthesiologists Physical Status (ASA-PS) class, type of surgery, and complications within 30 postoperative days were retrospectively collected from the medical records of nonagenarians who underwent open spine surgery between April 2004 and July 2019 at our spine centers. Results: A total of 48 patients met the inclusion criteria of this study. All belong to ASA-PS class 2 (69%) or 3. Preoperative American Spinal Injury Association Impairment Scale grades in trauma group were grade A in 4 cases, B in 1 case, C in 5 cases, D in 11 cases, and E in 1 case. Major complications (deep surgical site infection, cardiac event, respiratory disorder, gastrointestinal hemorrhage, and renal failure) occurred in 13 cases, and the rate of overall perioperative complications was 45.8%. One patient who underwent cervical stabilization for cervical fracture dislocation died at postoperative 13 days due to respiratory disorder. The rates of major complications and overall perioperative complications were 3.6% and 14.3% in the degenerative group and 45.5% and 81.8% in the trauma group, respectively. Especially in the trauma group, respiratory disorder occurred in 7 cases, delirium in 11 cases, and urinary tract infection in 5 cases. Conclusions: Although the perioperative complication rate reached 81.8% in spinal trauma cases, the complication rate in degenerative disorders was relatively low as 14.3%. Open spine surgery for degenerative disorders can be relatively safe even in nonagenarians, whereas the risks of perioperative complications, including respiratory disorder and delirium, were high in spinal trauma cases.

Trends of Spine Surgeries during the First COVID-19 Semi-Lockdown: Survey in a Non-Epidemic Region in Japan.

Introduction: In the early phase of the coronavirus disease 2019 (COVID-19) pandemic, the importance of triaging surgeries was suggested to reduce burdens on the existing health system and maintaining service. The governor declared a state of emergency and requested that residents avoid going out unnecessarily (semi-lockdown) for the entire prefecture including our medical region from February 28 until May 25, 2020. However, for several spine patients, a significant delay in care may result in the progression of extremity weakness and pain. This study aimed to investigate trends of spine surgeries during the first COVID-19 semi-lockdown in the nonepidemic region in Japan. Methods: Spine surgeries performed in our institution from February 28 until May 25 between 2017 and 2020 were retrospectively reviewed and analyzed. We compared the number of spine surgeries and types of surgical spine pathologies between 2017 and 2019: previous years and 2020: a COVID-19 year. Results: The mean number of spine surgeries performed in previous years was 121 cases, and the number of spine surgeries performed in a COVID-19 year was 109 cases. The percentage of urgent surgeries was 19.6% in previous years versus 37.6% in a COVID-19 year; the difference was statistically significant (P<0.05). Among the urgent surgical spine pathologies, the prevalence of cauda equina or severe nerve root compression leading to progressive neurological deterioration or intractable pain was 20.2% in a COVID-19 year, which was significantly higher than 12.4% in previous years (P<0.05). Conclusions: The first COVID-19 semi-lockdown in Japan led to a decrease in elective cases and an increase in urgent cases and might affect progressive neurological deterioration for some spine patients even in a nonepidemic region.

Clinical Outcomes and Postoperative Radiographic Assessment of Osteoplastic Hemilaminectomy in the Treatment of Lumbar Foraminal Nerve Root Compression.

INTRODUCTION: Osteoplastic hemilaminectomy for the treatment of lumbar foraminal nerve root compression is a safe technique as the exiting nerve root can be directly observed during neuroforaminal decompression without spinal fusion. Moreover, this procedure allows anatomical reconstruction of the posterior elements. However, there might be a potential risk for the progression of lumbar segmental instability after performing this procedure. This study aimed to review the radiographic and clinical outcomes of osteoplastic hemilaminectomy for the treatment of lumbar foraminal nerve root compression. METHODS: We retrospectively reviewed 51 patients who underwent osteoplastic hemilaminectomy with a minimum follow-up of 2 years. The clinical outcomes were evaluated using the visual analog scale (VAS) for low back pain, leg pain, and numbness and the Japanese Orthopaedic Association (JOA) score. Lumbar segmental instability was evaluated as a radiographic assessment using functional radiography. The mean follow-up period was 65 months. RESULTS: The preoperative VASs for low back pain, leg pain, and numbness were 46±31, 72±26, and 43±34, respectively, which were improved to 24±23, 19±23, and 19±23, respectively. The JOA score was also improved from 14±5 to 22±4. Three patients (5.9%) were reoperated due to recurrent disc herniation within 2 years following surgery. In addition, three patients (5.9%) developed postoperative lumbar segmental instability but did not require additional surgery. CONCLUSIONS: The current study revealed that 94.1% of the patients who underwent osteoplastic hemilaminectomy achieved a significant improvement in the clinical outcomes and did not require additional surgery within 2 years following the procedure. Over a 5-year follow-up on average, 5.9% of the subjects developed postoperative lumbar segmental instability; however, they have maintained acceptable clinical conditions.

Surgical treatment for lumbar hyperlordosis after resection of a spinal lipoma associated with spina bifida: A case report.

RATIONALE: A hyperlordosis deformity of the lumbar spine is relatively rare, and surgical treatment has not been comprehensively addressed. In this case report, we describe the clinical presentation, surgical treatment, and medium-term follow-up of a patient presenting with a progressive lumbar hyperlordosis deformity after resection of a spinal lipoma associated with spina bifida. PATIENT CONCERNS: The patient was a 20-year-old woman presenting with a progressive hyperlordosis deformity of the lumbar spine associated with significant back pain (visual analog pain score of 89/100 mm), but with no neurological symptoms. DIAGNOSES: The lumbar lordosis (LL), measured on standing lateral view radiographs, was 114°, with a sagittal vertical axis (SVA) of -100 mm. The patient had undergone excision of a lipoma, associated with spina bifida of the lumbar spine, at 7 months of age.She was first evaluated at our hospital at 18 years of age for progressive spinal deformity and lumbago. INTERVENTIONS: An in situ fusion, from T5 to S1, using pedicle screws with bone graft obtained from the iliac crest, was performed. OUTCOMES: Postoperatively, the LL decreased to 93°, and the SVA decreased to -50 mm. The decision to not correct the hyperlordosis deformity fully was intentional. Seven years and 1 month postsurgery, the patient had no limitations in standing and walking and reported a pain score of 8/100 mm; there was no evidence of a loss of correction. LESSONS: Lumbar hyperlordosis after resection of a spinal lipoma associated with spina bifida is rare. Posterior fixation provided an effective treatment in this case. As the lumbar hyperlordosis deformity is often high, correction can be difficult. In this case, although the correction and fusion were performed in situ, there was no progression of either the deformity or the lumbago. Early detection remains an essential component of effective treatment, allowing correction when the spinal deformity is easily reversible.

Spontaneous improvement of cervical kyphosis in eosinophilic granuloma: a case report.

We describe the case of a spontaneous improvement of the cervical kyphosis in eosinophilic granuloma with long-term follow-up. A collapse of the C5 vertebral body was confirmed by cervical spine radiography and computed tomography. The patient wore a sterno-occipitalmandibular immobilizer brace for 6 months, and remodeling of the vertebral body was confirmed 18 months after onset. Seven years have passed since the onset of symptoms, and the patient's cervical spine has maintained normal alignment. Management of eosinophilic granuloma of the pediatric cervical spine is still controversial. Conservative treatment suffices as adequate management of cervical eosinophilic granuloma, even with kyphotic deformity.