Ligamentum Flavum Hematoma Accompanied by Intraspinal and Extraspinal Hematomas: A Case Report.

Studies on ligamentum flavum hematoma (LFH) have been gradually increasing; however, no study has reported an LFH spreading to the intraspinal and extraspinal spaces. The purpose of this report is to discuss this rare condition and report that extraspinal hematoma can be formed by LFH. The authors present the case of a 78-year-old man presented with right L5 radiculopathy caused by a space-occupying lesion with intraspinal and extraspinal expansions at the L4-L5 vertebral levels demonstrated on MRI. We tentatively diagnosed these lesions as intraspinal and extraspinal hematomas originating from the ligamentum flavum based on the chronological changes seen on MRI and computed tomography-based needle biopsy. After the extirpation of these lesions, the symptoms were relieved. Three months later, the patient could walk without a cane. From the intraoperative findings and pathological examination, we concluded that the extraspinal hematoma in paravertebral muscle was caused by an LFH of unknown etiology. This case report describes the difficulty in diagnosing LFH accompanied by an extraspinal hematoma with wide-spreading expansion and highlights the usefulness of repetitive MRI over time in capturing chronological changes of the hematoma. As far as we know, this is the first study on an LFH accompanied by an extraspinal hematoma in the multifidus.

Perpendicular probing and screwing technique: A simple method for accurate pedicle screw placement based on the human internal reference frame for angle estimation.

The pedicle screw (PS) is widely used for spinal fixation surgery. However, PS malpositioning can cause critical complications; thus, the accuracy of ascertaining PS trajectory is paramount. This study aimed to demonstrate the accuracy and safety of a simple and cost-effective PS placement technique using a human internal reference frame for angle estimation. Ex vivo lumbar porcine spine samples were fixed to a wooden board with rostrocaudal and mediolateral rotational angles adjusted by two angle vises. PS entry points (EPs) were identified using clear anatomical vertebral landmarks. PS placement was performed on one side using the perpendicular probing and screwing technique (PPST), wherein the attitude angle of the sample was adjusted such that the longitudinal axis of the target pedicle was perpendicular to the ground. The pedicle probe and PS driver were manually maintained perpendicular to the ground during probing and PS placement. PS placement on the contralateral side was performed freehand as a control. Offsets between the preoperatively planned and implanted PS rotational angles measured using computed tomography for PPST and freehand method were analyzed. Pedicle wall penetration was also evaluated. The mean ± standard error of the medial rotational offsets was 5.83° ± 0.57° in the freehand group versus 2.89° ± 0.31° in the PPST group (p <0.001), and the rostrocaudal rotational offsets were 4.81° ± 0.65° in the freehand group versus 2.92° ± 0.45° in the PPST group (p = 0.01). The mean pedicle wall penetration distance was significantly reduced by PPST (0.28 ± 0.12 mm vs 0.80 ± 0.17 mm in the freehand group, p = 0.0071). Thus, PPST improved PS positioning accuracy, resulting in reduced pedicle wall penetration and increased PS placement safety. This simple technique is also potentially cost-effective for institutions without computer-assisted surgical systems.

Predictive factors of mortality of patients with fragility hip fractures at 1 year after discharge: A multicenter, retrospective study in the northern Kyushu district of Japan.

PURPOSE: Fragility hip fractures (FHFs) are associated with a high risk of mortality, but the relative contribution of various factors remains controversial. This study aimed to evaluate predictive factors of mortality at 1 year after discharge in Japan. METHODS: A total of 497 patients aged 60 years or older who sustained FHFs during follow-up were included in this study. Expected variables were finally assessed using multivariable Cox proportional hazards models. RESULTS: The 1-year mortality rate was 9.1% (95% confidence interval: 6.8-12.0%, n = 45). Log-rank test revealed that previous fractures (p = 0.003), Barthel index (BI) at discharge (p = 0.011), and place-to-discharge (p = 0.004) were significantly associated with mortality for male patients. Meanwhile, body mass index (BMI; p = 0.023), total Charlson comorbidity index (TCCI; p = 0.005), smoking (p = 0.007), length of hospital stay (LOS; p = 0.009), and BI (p = 0.004) were the counterparts for females. By multivariate analyses, previous vertebral fractures (hazard ratio (HR) 3.33; p = 0.044), and BI <30 (HR 5.42, p = 0.013) were the predictive variables of mortality for male patients. BMI <18.5 kg/m2 (HR 2.70, p = 0.023), TCCI ≥5 (HR 2.61, p = 0.032), smoking history (HR 3.59, p = 0.018), LOS <14 days (HR 13.9; p = 0.007), and BI <30 (HR 2.76; p = 0.049) were the counterparts for females. CONCLUSIONS: Previous vertebral fractures and BI <30 were the predictive variables of mortality for male patients, and BMI <18.5 kg/m2, TCCI ≥5, smoking history, LOS <14 days, and BI <30 were those for females. Decreased BI is one of the independent and preventable risk factors. A comprehensive therapeutic approach should be considered to prevent deterioration of activities of daily living and a higher risk of mortality.

Radiological Examination of Postoperative Cervical Alignment and Stability in Patients with Dialysis-Associated Spondylosis Excluding Destructive Spondyloarthropathy: Comparison with Patients with Cervical Spondylotic Myelopathy.

INTRODUCTION: Several reports have demonstrated the surgical treatment strategy for patients with dialysis-associated spondylosis in the cervical spine (CDAS) with destructive spondyloarthropathy (DSA). However, studies focusing on the clinical outcome of patients with CDAS without DSA remain scarce. We aimed to review the treatment strategy of patients with CDAS but without DSA. METHODS: The clinical data and surgical records of consecutive patients with CDAS without DSA (n = 9; D-group) and cervical spondylotic myelopathy (CSM) (n = 30; C-group) who underwent modified double-door laminoplasty(DDL) were reviewed retrospectively. We investigated four radiologic factors in the pre-and postoperative periods that have been reported to be the risk factors for worsening of clinical symptoms in various studies and examined statistical comparison between the D and C groups. RESULTS: In the D group, the pre- versus postoperative C2-C7 sagittal angles were not significantly different, and only two patients (22%) had kyphosis postoperatively. There was a significant difference in the pre- and postoperative C2-C7 angles in the two groups (P = 0.031). Regarding the change in segmental alignment, the local open angle increased at the C4/C5 level in the D group. Also there was a significant difference in the local angles between the two groups at C4/5 and C5/6 (P = 0.00038, and 0.037), suggesting that postoperative segmental mobility at C4/5 and C5/6 was higher in the D group than in the C group. CONCLUSIONS: In the present study, DDL in patients with CDAS without DSA did not adversely affect the postoperative alignment and stability compared with CSM patients with CSM. However, patients in the D group may have a chance to develop DSA change at the C4/5 level in the future, and careful long-term follow-up is warranted.

Characteristics of patients with fragility hip fractures in the northern Kyushu district in Japan: a multicenter prospective registry based on an electronic data capture system.

Osteoporosis has become a worldwide public health problem, in part due to the fact that it increases the risk of fragility hip fractures (FHFs). The epidemiological assessment of FHFs is critical for their prevention; however, datasets for FHFs in Japan remain scarce. This was a multicenter, prospective, observational study in the northern district of Kyushu Island. Inclusion criteria were age > 60 years with a diagnosis of FHF and acquisition of clinical data by an electronic data capture system. Of 1294 registered patients, 1146 enrolled in the study. Nearly one third of patients (31.8%) had a history of previous fragility fractures. The percentage of patients receiving osteoporosis treatment on admission was 21.5%. Almost all patients underwent surgical treatment (99.1%), though fewer than 30% had surgery within 48 h after hospitalization. Bone mineral density (BMD) was evaluated during hospitalization in only 50.4% of patients. The rate of osteoporosis treatment increased from 21.5% on admission to 39.3% during hospitalization. The main reasons that prescribers did not administer osteoporosis treatment during hospitalization were forgetfulness (28.4%) and clinical judgment (13.6%). Age and female ratio were significantly higher in patients with previous FHFs than in those without. There was a significant difference in the rate of osteoporosis treatment or L-spine BMD values in patients with or without previous FHFs on admission. In conclusion, this study confirmed that the evaluation and treatment of osteoporosis and FHFs is still suboptimal in Japan, even in urban districts.

Risk factors for re-recurrent carpal tunnel syndrome in patients undergoing long-term hemodialysis.

The purpose of this study was to evaluate risk factors for re-recurrent carpal tunnel syndrome (CTS) in long-term renal hemodialysis (HD) patients. Fifteen wrists of ten HD patients, follow-up period of minimum seven years after reoperation of CTS, were included in this study. Duration of HD, period from first operation to reoperation, shunt side was involved or not, presence of trigger finger and cervical destructive spondyloarthritis, and operative procedure performed during the reoperation (synovectomy was performed or not) were evaluated. Re-recurrent CTS was identified in four out of 15 wrists (27%). The period from first operation to reoperation, which was 3.8 years in the re-recurrence group and eight years in the no re-recurrence group, and the operative procedure had significant differences (synovectomy groups had no re-recurrence vs. no synovectomy groups had 82% re-recurrence). The results of this study suggested that synovectomy would be necessary for recurrent CTS in HD patients.