Navigation-Assisted Micro-Window Excision of Thoracic Ossification of Ligamentum Flavum (Mishima Surgery) in Professional Baseball Pitchers: A Case Report and Technical Note.

Background and Objectives: Thoracic ossification of the ligamentum flavum (OLF) often causes myelopathy and/or radiculopathy. The disease is frequently observed in East Asian populations. Although thoracic OLF in young athletes who have underwent decompression surgery has been reported, the removal of posterior spinal bony elements and ligamentous complex may often cause postoperative thoracolumbar instability. We established a novel surgical technique that preserves the posterior spinal elements, including the spinous processes, facet joints, and supraspinous and interspinous ligaments for thoracic OLF. This is the first case report to describe a navigation-assisted micro-window excision of thoracic OLF. Case: A 32-year-old male right-handed professional baseball pitcher with significant weakness and numbness in the left leg was referred to our hospital. The patient was diagnosed with thoracic OLF at T10-11 based on radiographic and magnetic resonance images in August 2022. After exposure of the left T10-11 laminae via a small unilateral incision, the location of T10-11 OLF was detected over the lamina by O-arm navigation. Then, the micro-window was made directly above the OLF using a navigated air drill, and the OLF was removed on the ipsilateral side. The contralateral side of OLF was also resected through the same micro-window, achieving complete spinal cord decompression. Results: The next day of the surgery, his leg weakness and numbness were significantly improved. Six weeks after the surgery, he started pitching. Three months after surgery, his symptoms had gone completely, and he pitched from the mound. Approximately 6 months after surgery, he successfully pitched in a professional baseball game. Conclusions: A navigation-assisted micro-window excision of thoracic OLF effectively preserved the spinal posterior bony elements and ligamentous complex. However, long-term clinical outcomes should be evaluated in future studies.

Association between the Phase Angle and the Severity of Horizontal Gaze Disorder in Patients with Idiopathic Dropped Head Syndrome: A Cross-Sectional Study.

Background and Objectives: The phase angle, calculated by bioelectrical impedance analysis, can help elucidate the pathology of patients with idiopathic dropped head syndrome (IDHS) and explain the motor dysfunction associated with the horizontal gaze disorder. The aim of this study was to clarify the characteristics of phase angle in IDHS patients and the relationship between the phase angle and the severity of horizontal gaze disorder. Materials and Methods: This cross-sectional study included 43 female patients with IDHS and 69 healthy female volunteers. A multi-frequency segmental body composition analyzer was used to calculate body composition parameters, including whole-body and lower extremity phase angles. Propensity score (PS) matching analysis was performed to compare the body composition parameters between the IDHS and healthy groups. Variables that determine the PS were identified by correlation analysis, using the whole-body phase angle as the dependent variable. In addition, correlation analysis was performed between the severity of horizontal gaze disorder as assessed by McGregor's slope (McGS), phase angle, and other body composition parameters. Results: Unadjusted group comparisons showed no significant difference in whole-body and lower extremity phase angles between the IDHS and healthy groups. PS matching created a total of 38 matched pairs for age, height, and fat-free mass index. Although the comparison between groups of matched samples showed no significant difference in the whole-body phase angle, the lower extremity phase angle in the IDHS group was significantly lower than that in the healthy group (p = 0.033). Correlation analysis showed significant negative correlations only between McGS and whole-body (r = -0.31, p = 0.043) and lower extremity phase angle (r = -0.39, p = 0.009) in the IDHS group. Conclusions: Abnormal body composition of the lower extremities were observed in IDHS patients. Furthermore, it was suggested that horizontal gaze disorder in IDHS patients is associated with whole-body and lower extremity phase angles.

Minimally Invasive Spine Stabilization for Pyogenic Spondylodiscitis: A 23-Case Series and Review of Literature.

Background and Objectives: The incidence of pyogenic spondylodiscitis has been increasing due to the aging of the population. Although surgical treatment is performed for refractory pyogenic spondylodiscitis, surgical invasiveness should be considered. Recent minimally invasive spine stabilization (MISt) using percutaneous pedicle screw (PPS) can be a less invasive approach. The purpose of this study was to evaluate surgical results and clinical outcomes after MISt with PPS for pyogenic spondylodiscitis. Materials and Methods: Clinical data of patients who underwent MISt with PPS for pyogenic spondylitis were analyzed. Results: Twenty-three patients (18 male, 5 female, mean age 67.0 years) were retrospectively enrolled. The mean follow-up period was 15.9 months after surgery. The causative organism was identified in 16 cases (69.6%). A mean number of fixed vertebrae was 4.1, and the estimated blood loss was 145.0 mL. MISt with PPS was successfully performed in 19 of 23 patients (82.6%). Four cases (17.4%) required additional anterior debridement and autologous iliac bone graft placement. CRP levels had become negative at an average of 28.4 days after surgery. There was no major perioperative complication and no screw or rod breakages during follow-up. Conclusions: MISt with PPS would be a less invasive approach for pyogenic spondylodiscitis in elderly or immunocompromised patients.

Respective Correction Rates of Lateral Lumbar Interbody Fusion and Percutaneous Pedicle Screw Fixation for Lumbar Degenerative Spondylolisthesis.

Background and Objectives: There are few reports describing the radiographic correction of vertebral slippage in lateral interbody fusion and percutaneous pedicle screw fixation for lumbar degenerative spondylolisthesis. [Objectives] We evaluated the intraoperative surgical correction obtained by lateral interbody fusion and percutaneous pedicle screw procedures. Materials and Methods: Fifty patients were included in this study. According to the Meyerding classification, 35 cases were Grade 1 and 15 cases were Grade 2. Mean age was 64.7 ± 6.4 years old. Seventeen cases were male, and 33 cases were female. The mean preoperative % slip was 21.1 ± 7.0%. After lateral interbody fusion, vertebral slippage was corrected using reduction technique by percutaneous pedicle screw. Results: The slippage of vertebra was reduced to 11.5 ± 6.5% after lateral interbody fusion procedure and 4.0 ± 6.0% after percutaneous pedicle screw procedure. One year after surgery, the slippage of vertebra was 4.1 ± 6.6%. The correction rate of lateral interbody fusion was 47.7 ± 25.1%, and that of percutaneous pedicle screw was 33.8 ± 2.6%. The total correction rate was 81.5 ± 27.7%. There was no significant loss of correction one year after surgery. The Japanese Orthopaedic Association Score significantly improved from 14.7 ± 4.2 to 27.7 ± 1.7 points at final follow up. No vascular or organ injury was observed during surgery, and there were no postoperative surgical site infections or systemic complications. Conclusion: Compared with previous reports, the final correction rate and the correction rate of the percutaneous pedicle screw procedure were particularly high in this study. Lateral interbody fusion and percutaneous pedicle screw using reduction technique provide excellent clinical and radiographic outcomes for patients with lumbar degenerative spondylolisthesis.

Computed Tomography-Based Navigation System in Current Spine Surgery: A Narrative Review.

The number of spine surgeries using instrumentation has been increasing with recent advances in surgical techniques and spinal implants. Navigation systems have been attracting attention since the 1990s in order to perform spine surgeries safely and effectively, and they enable us to perform complex spine surgeries that have been difficult to perform in the past. Navigation systems are also contributing to the improvement of minimally invasive spine stabilization (MISt) surgery, which is becoming popular due to aging populations. Conventional navigation systems were based on reconstructions obtained by preoperative computed tomography (CT) images and did not always accurately reproduce the intraoperative patient positioning, which could lead to problems involving inaccurate positional information and time loss associated with registration. Since 2006, an intraoperative CT-based navigation system has been introduced as a solution to these problems, and it is now becoming the mainstay of navigated spine surgery. Here, we highlighted the use of intraoperative CT-based navigation systems in current spine surgery, as well as future issues and prospects.

The Short and Intensive Rehabilitation (SHAiR) Program Improves Dropped Head Syndrome Caused by Amyotrophic Lateral Sclerosis: A Case Report.

Background and Objectives: Dropped head syndrome (DHS) is a syndrome that presents with correctable cervical kyphotic deformity as a result of weakening cervical paraspinal muscles. DHS with amyotrophic lateral sclerosis (ALS) is a relatively rare condition, and there is no established treatment. This is the first case report describing the improvement of both dropped head (DH) and cervical pain after the short and intensive rehabilitation (SHAiR) program in an ALS patient with DHS. Case Report: After being diagnosed with ALS in June 2020, a 75-year-old man visited our hospital in October 2020 to receive treatment for DHS. At the initial visit, the patient's DH was prominent during standing and walking. The pain intensity of the neck was 9 out of 10 on the numerical rating scale (NRS), which was indicative of severe pain. The patient was hospitalized for 2 weeks and admitted into the SHAiR program. DH began to decrease one week after undergoing the SHAiR program and improved two weeks later. Neck pain decreased from 9 to 6 on the NRS. Results: The SHAiR program is a rehabilitation program aimed at improving DH in patients with idiopathic DHS. The program was designed to improve neck extensor and flexor function and global spinal alignment, and the program may have contributed to the improvement of DH and neck pain. Currently, reports of conservative therapies for this disease are limited to the use of cervical orthosis. Although further research is needed on the safety and indications of treatment, the SHAiR program may be a viable treatment option.

The History and Development of the Percutaneous Pedicle Screw (PPS) System.

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) using the SEXTANT® system (Medtronic) featured the first generation of commercially available percutaneous pedicle screw (PPS) system in 2001. The innovative system has since become standard instrumentation used worldwide, and PPS is now used for long-segment minimally invasive surgery (MIS) spinal fixation from the thoracic spine to the pelvis for pathological conditions. PPS systems have been developed for approximately 20 years for the purpose of improving minimally invasive techniques, safety of instrumentation, and ease of use. The third-generation PPS systems established the insertion technique, and the development of the fourth-generation PPS systems have made great strides in minimizing the number of steps in the operative procedure. In the future, PPS systems are expected to continue making use of the latest technological advancements and to develop further with the aim of ensuring greater safety, reducing operator stress, and preventing complications such as insertion errors and infection. In this review article, we describe the historical evolution from the first-generation PPS system to the current PPS systems used today.

Association between the Horizontal Gaze Ability and Physical Characteristics of Patients with Dropped Head Syndrome.

Background and Objectives: Patients with dropped head syndrome exhibit weakness of the cervical paraspinal muscles. However, the relationship between horizontal gaze disorder and physical function remains unclear. This study aimed to examine and clarify this relationship. Materials and Methods: Ninety-six patients with dropped head syndrome were included. We measured the McGregor's Slope and investigated physical characteristics, including cervical muscle strength, back muscle strength, and walking ability. Factor analysis was used to classify the characteristics of physical function, and a linear multiple regression analysis was used to evaluate independent variables explaining the variance in the McGregor's Slope. The physical functions of DHS patients were classified into three categories by factor analysis: limb and trunk muscle strength, walking ability, and neck muscle strength. Results: The average value of the McGregor's Slope was 22.2 ± 24.0 degrees. As a result of multiple regression analysis, walking speed (ß = -0.46) and apex (ß = -0.30) were extracted as significant factors influencing the McGregor's Slope. Conclusions: Horizontal gaze disorders are not associated with cervical muscle strength but with the walking ability and the alignment type of dropped head syndrome.

Minimally Invasive Spinal Treatment (MIST)-A New Concept in the Treatment of Spinal Diseases: A Narrative Review.

In the past two decades, minimally invasive spine surgery (MISS) techniques have been developed for spinal surgery. Historically, minimizing invasiveness in decompression surgery was initially reported as a MISS technique. In recent years, MISS techniques have also been applied for spinal stabilization techniques, which were defined as minimally invasive spine stabilization (MISt), including percutaneous pedicle screws (PPS) fixation, lateral lumbar interbody fusion, balloon kyphoplasty, percutaneous vertebroplasty, cortical bone trajectory, and cervical total disc replacement. These MISS techniques typically provide many advantages such as preservation of paraspinal musculature, less blood loss, a shorter operative time, less postoperative pain, and a lower infection rate as well as being more cost-effective compared to traditional open techniques. However, even MISS techniques are associated with several limitations including technical difficulty, training opportunities, surgical cost, equipment cost, and radiation exposure. These downsides of surgical treatments make conservative treatments more feasible option. In the future, medicine must become "minimally invasive" in the broadest sense-for all patients, conventional surgeries, medical personnel, hospital management, nursing care, and the medical economy. As a new framework for the treatment of spinal diseases, the concept of minimally invasive spinal treatment (MIST) has been proposed.

Baseline severity of myelopathy predicts neurological outcomes after posterior decompression surgery for cervical spondylotic myelopathy: a retrospective study.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVES: To identify the usefulness of the baseline severity of myelopathy for predicting surgical outcomes for cervical spondylotic myelopathy (CSM). SETTING: Seventeen institutions in Japan. METHODS: This study included 675 persons with CSM who underwent posterior decompression. According to baseline severity, the individuals were divided into the mild (Japanese Orthopaedic Association [JOA] score ≥ 14.5), moderate (JOA score = 10.5-14), and severe (JOA score ≤ 10) groups. Surgical outcomes and clinical variables were compared between the groups. Logistic regression analysis was used to develop a prediction model for unsatisfactory symptom state (postoperative JOA score ≤ 14, residual moderate or severe myelopathy). RESULTS: The mean (±standard deviation) age was 67 ± 12 years. The participants in the severe group were older than those in the mild group. Postoperative JOA scores were higher in the mild group than in the severe group. According to multivariate logistic regression analysis, the prediction model included preoperative JOA scores (odds ratio [OR] 0.60; 95% confidence interval [CI] 0.55-0.67) and age (OR 1.06, 95% CI 1.04-1.08). On the basis of the model, a representative combination of the thresholds to maximize the value of "sensitivity - (1 - specificity)" demonstrated a preoperative JOA score of 11.5 as a predictor of postoperative unsatisfactory symptom state in people around the mean age of the study cohort (67 years). CONCLUSIONS: The combination of the baseline severity of myelopathy and age can predict postoperative symptom states after posterior decompression surgery for CSM.

Idiopathic dorsal spinal cord herniation perforating the lamina: a case report and review of the literature.

Spinal cord herniation (SCH) is a rare condition associated with tethering of the spinal cord at the ventral dural defect. Idiopathic dorsal spinal cord herniation (IDSCH) is an extremely rare clinical entity. Here, we report the first case of IDSCH perforating the lamina in a patient with a history of ossification of the ligamentum flavum and diffuse idiopathic skeletal hyperostosis. Untethering of the spinal cord was performed by removing the surrounded ossified dura. Although urological symptoms and impaired proprioception remained, progressive neurological deterioration was prevented. Because this disease condition is extremely rare, it should be differentiated from ventral SCH.

Risk predictors of perioperative complications for the palliative surgical treatment of spinal metastasis.

BACKGROUND: The complication rate for palliative surgery in spinal metastasis is relatively high, and major complications can impair the patient's activities of daily living. However, surgical indications are determined based primarily on the prognosis of the cancer, with the risk of complications not truly considered. We aimed to identify the risk predictors for perioperative complications in palliative surgery for spinal metastasis. METHODS: A multicentered, retrospective review of 195 consecutive patients with spinal metastasis who underwent palliative surgeries with posterior procedures from 2001 to 2016 was performed. We evaluated the type and incidence of perioperative complications within 14 days after surgery. Patients were categorized into either the complication group (C) or no-complication group (NC). Univariate and multivariate analyses were used to identify potential predictors for perioperative complications. RESULTS: Thirty patients (15%) experienced one or more complications within 14 days of surgery. The most frequent complications were surgical site infection (4%) and motor weakness (3%). A history of diabetes mellitus (C; 37%, NC; 9%: p < 0.01) and surgical time over 300 min (C; 27%, NC; 12%: p < 0.05) were significantly associated with complications according to univariate analysis. Increased blood loss and non-ambulatory status were determined to be potential risk factors. Of these factors, multivariate logistic regression revealed that a history of diabetes mellitus (OR: 6.6, p < 0.001) and blood loss over 1 L (OR: 2.7, p < 0.05) were the independent risk factors for perioperative complications. There was no difference in glycated hemoglobin A1c between the diabetes patients with and without perioperative complications. CONCLUSIONS: Diabetes mellitus should be used for the risk stratification of surgical candidates regardless of the treatment status, and strict prevention of bleeding is needed in palliative surgeries with posterior procedures to mitigate the risk of perioperative complications.

The factors related to the poor ADL in the patients with osteoporotic vertebral fracture after instrumentation surgery.

PURPOSE: Osteoporotic vertebral fracture (OVF) with nonunion or neurological deficit may be a candidate for surgical treatment. However, some patients do not show improvement as expected. Therefore, we conducted a nationwide multicenter study to determine the predictors for postoperative poor activity of daily living (ADL) in patients with OVF. METHODS: We retrospectively reviewed the case histories of 309 patients with OVF who underwent surgery. To determine the factors predicting postoperative poor ADL, uni- and multivariate statistical analyses were performed. RESULTS: The frequency of poor ADL at final follow-up period was 9.1%. In univariate analysis, preoperative neurological deficit (OR, 4.1; 95% CI, 1.8-10.3; P < 0.001), perioperative complication (OR, 3.4; P = 0.006), absence of preoperative bone-modifying agent (BMA) administration (OR, 2.7; P = 0.03), and absence of postoperative recombinant human parathyroid hormone (rPTH) administration (OR, 3.9; P = 0.006) were significantly associated. In multivariate analysis, preoperative neurological deficit (OR, 4.6; P < 0.001), perioperative complication (OR, 3.4; P = 0.01), and absence of postoperative rPTH administration (OR, 3.9; P = 0.02) showed statistical significance. CONCLUSIONS: Preoperative neurological deficit, perioperative complication, and absence of postoperative rPTH administration were considered as predictors for postoperative poor ADL in patients with OVF. Neurological deficits and complications are often inevitable factors; therefore, rPTH is an important option for postoperative treatment for OVF. These slides can be retrieved under Electronic Supplementary Material.

Patients majoring in a healthcare field after scoliosis surgery: Comparison with the national census in Japan.

BACKGROUND: Although scoliosis surgery early in life may affect the career choice of the patient in favor of a healthcare field, no study has analyzed this relationship. We investigated the career paths of patients after scoliosis surgery. METHODS: A total of 212 patients with scoliosis who underwent corrective surgery at 12-17 years of age were mailed a questionnaire, of whom 98 (mean age at survey: 21.0 ± 1.7, years) responded. Choice of study major was determined by the same questions used in the Japanese national census. RESULTS: Of the 98 patients, 35% chose a career in healthcare compared with 11% of the general population of the same age, based on the national census. Healthcare was the most popular career choice of patients, whereas it ranked fourth according to the national census. Furthermore, 87% of patients reported that their decision to pursue a healthcare-related career was affected by their own medical experiences. Among the healthcare-related occupations, nursing ranked first, accounting for 35% of all healthcare professions chosen by the patients. Compared with patients who chose a non-healthcare career, those choosing a healthcare career decided on their study major at a significantly lower age. CONCLUSIONS: One-third of patients with scoliosis who underwent spine surgery chose a career in a healthcare field. Furthermore, an earlier age at the time of making a career decision was a significant factor associated with choosing a healthcare career. These findings suggest that the patients' experiences in the hospital positively affected their future career paths.

Complications after spinal fixation surgery for osteoporotic vertebral collapse with neurological deficits: Japan Association of Spine Surgeons with ambition multicenter study.

BACKGROUND: There have been few reports on the incidence and risk factors of the complications after spinal fixation surgery for osteoporotic vertebral collapse (OVC) with neurological deficits. This study aimed to identify the incidence and risk factors of the complications after OVC surgery. METHODS: In this retrospective multicenter study, a total of 403 patients (314 women and 89 men; mean age 73.8 years) who underwent spinal fixation surgery for OVC with neurological deficits between 2005 and 2014 were enrolled. Data on patient demographics were collected, including age, sex, body mass index, smoking, steroid use, medical comorbidities, and surgical procedures. All postoperative complications that occurred within 6 weeks were recorded. Patients were classified into two groups, namely, complication group and no complication group, and risk factors for postoperative complications were investigated by univariate and multivariate analyses. RESULTS: Postoperative complications occurred in 57 patients (14.1%), and the most common complication was delirium (5.7%). In the univariate analysis, the complication group was found to be older (p = 0.039) and predominantly male (p = 0.049), with higher occurrence rate of liver disease (p = 0.001) and Parkinson's disease (p = 0.039) compared with the no-complication group. In the multivariate analysis, the significant independent risk factors were age (p = 0.021; odds ratio [OR] 1.051, 95% confidence interval [CI] 1.007-1.097), liver disease (p < 0.001; OR 8.993, 95% CI 2.882-28.065), and Parkinson's disease (p = 0.009; OR 3.636, 95% CI 1.378-9.599). CONCLUSIONS: Complications after spinal fixation surgery for OVC with neurological deficits occurred in 14.1%. Age, liver disease, and Parkinson's disease were demonstrated to be independent risk factors for postoperative complications.

A rare case of intradural and extramedullary epidermoid cyst after repetitive epidural anesthesia: case report and review of the literature.

BACKGROUND: Spinal epidermoid cysts are benign tumors, which are rarely seen as an intradural extramedullary spinal cord tumor in the conus medullaris region. Acquired spinal epidermoid cysts are mostly caused by iatrogenic procedures, such as lumbar puncture, and the majority of acquired spinal epidermoid cysts have been reported below the L1 level, because lumbar puncture is usually performed around the iliac crest. Here, we report an extremely rare case of an epidermoid cyst that occurred as an intradural and extramedullary spinal cord tumor attached to the conus medullaris after repetitive epidural anesthesia. CASE PRESENTATION: A 67-year-old female presented with a low back pain and left sciatica. Although the patient had experienced occasional mild low back pain for several years, her low back pain markedly worsened 2 months before her visit, as well as newly developed left sciatica resulting in intermittent claudication. She had a history of several abdominal surgeries. All abdominal procedures were performed under general anesthesia with epidural anesthesia in her thoracolumbar spine. Magnetic resonance imaging of her lumbar spine demonstrated an intradural extramedullary spinal cord tumor at the T12-L1 level. Because her symptoms deteriorated, the tumor excision was performed using microscopy. Histological examination of the specimens demonstrated that the cyst walls lined with stratified squamous keratinizing epithelium surrounded by the outer layer of collagenous tissue with the absence of skin adnexa. A diagnosis of epidermoid cysts was confirmed. Her MRI showed complete resection of the tumor, and there was no recurrence at 2-year follow-up. CONCLUSIONS: In this case report, epidermoid cells might be contaminated into the spinal canal during repetitive epidural anesthesia. The patient was successfully treated by complete resection, and there was no recurrence at 2-year follow-up with a good clinical outcome. However, long-term follow-up is required for a potential risk of tumor recurrence.

Comparison of Surgical Outcomes After Posterior Decompression by Junior or Senior Surgeons for Patients With Cervical Ossification of the Posterior Longitudinal Ligament: Results From Retrospective Multicenter Cohort Study.

STUDY DESIGN: Retrospective multicenter study. OBJECTIVES: To investigate surgical outcomes following posterior decompression for cervical ossification of the posterior longitudinal ligament (OPLL) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons. METHODS: We included 203 patients with cervical OPLL who were followed for a minimum of 1 year after surgery. Demographic information, medical history, and imaging findings were collected. Clinical outcomes were assessed preoperatively and at the final follow-up using the Japanese Orthopedic Association (JOA) score and the visual analog scale (VAS) for the neck. We compared outcomes between BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and NBCS surgeons. RESULTS: BCS surgeons performed 124 out of 203 cases, while NBCS surgeons were primary in 79 cases, with 73.4% were directly supervised by a BCS surgeon. There was no statistically significant difference in surgical duration, estimated blood loss, and perioperative complication rates between the BCS and NBCS groups. Moreover, no statistically significant group differences were observed in each position of the C2-7 angle and cervical range of motion at preoperation and the final follow-up. Preoperative and final follow-up JOA scores, VAS for the neck, and JOA score recovery rate were comparable between the two groups. CONCLUSIONS: Surgical outcomes, including functional recovery, complication rates, and cervical dynamics, were comparable between the BCS and NBCS groups. Consequently, posterior decompression for cervical OPLL is considered safe and effective when conducted by junior surgeons who have undergone training and supervision by experienced spine surgeons.

Comparative Study of Anticipatory Postural Adjustments between Normal and Cervical Myelopathy Patients.

Patients with cervical spondylotic myelopathy or ossification of the posterior longitudinal ligament have been considered to be prone to falls due to lower extremity dysfunction and gait instability. Anticipatory postural adjustments (APAs) are unconscious muscular activities to counterbalance perturbation. To date, there are no reports on APAs in cervical myelopathy patients, and quantification of postural control remains difficult. Thirty participants were enrolled, of which 15 were cervical myelopathy patients and 15 were normal age- and sex-matched controls. A three-dimensional motion capture system with force plates was used, and the APA phase was defined as the time between start of movement at the center of pressure and heel-off of the step leg. The APA phase (0.47 vs. 0.39 s, p < 0.05) and turning time (2.27 vs. 1.83 s, p < 0.01) were significantly longer, whereas step length tended to be shorter (305.18 vs. 361.04 mm, p = 0.06) in cervical myelopathy patients. There was a significant correlation between Japanese Orthopaedic Association lower extremity motor dysfunction scores and step length (p < 0.01). Cervical myelopathy patients are prone to falls due to longer APA phases with shorter step lengths. Analysis of the APA phase aids the visualization and quantification of postural control during initial gait in cervical myelopathy patients.

Radiographic Outcomes of the Short and Intensive Rehabilitation (SHAiR) Program in Patients with Dropped Head Syndrome.

Background: The radiographic outcomes of nonoperative treatment of dropped head syndrome are still unknown. The purpose of the present study was to assess the change in sagittal spinopelvic radiographic parameters after the short and intensive rehabilitation (SHAiR) program in patients with dropped head syndrome. Methods: This study included 48 consecutive patients with dropped head syndrome who presented with an inability to maintain horizontal gaze and who underwent the SHAiR program during the period of 2018 to 2019. Patients were divided into 2 groups according to their ability to maintain horizontal gaze at the time of final follow-up: those who had regained horizontal gaze (the "effective" group) and those who had not regained horizontal gaze (the "noneffective" group). Sagittal radiographic parameters including the sagittal vertical axis (SVA), the C2-7 angle, the C2-7 SVA, T1 slope, thoracic kyphosis of T1-5 and T5-12, lumbar lordosis, pelvic tilt, pelvic incidence, sacral slope, and curve flexibility, and demographic data and clinical outcomes were compared between the 2 groups using an unpaired t test, chi-square test, and Fisher exact test, as appropriate. Results: Thirty-five patients in the effective group and 13 patients in the noneffective group were analyzed. The rate of response in regaining horizontal gaze with the SHAiR program was 73%. The C2-7 angle, the C2-7 SVA, T1 slope, and thoracic kyphosis (T1-5) demonstrated significant correction in the effective group (p < 0.05). There were no significant changes in other parameters below the mid-thoracic spine-i.e., the thoracolumbar and lumbar spine and pelvis-following the SHAiR program. Scores of the Neck Disability Index and visual analog scale for pain improved significantly in both groups. Conclusions: The SHAiR program improved horizontal gaze among a large percentage of our patients and reduced cervical pain among patients overall. The correction of thoracic kyphosis (T1-5) might be an important treatment target to restore the appropriate T1 tilt in patients with dropped head syndrome. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Trunk orthosis with joints providing resistive force improves dynamic sagittal alignment in postoperative patients with lumbar spinal stenosis.

This study aimed to determine whether a trunk orthosis with joints providing resistive force (TORF) modifies sagittal malalignment during level walking in patients with lumbar spinal stenosis (LSS). Fifteen patients, 6 months after undergoing surgery for LSS, performed level walking at a self-selected speed while wearing a TORF. Dynamic sagittal alignment, including sagittal vertical axis, lumbar lordosis, and pelvic tilt, and spatiotemporal data as well as lower limb kinematic and kinetic data were recorded using a three-dimensional motion analysis system and six force plates. Statistical analysis was performed to compare these data with and without the TORF, respectively. Compared to the condition without the TORF, the use of the TORF significantly decreased positive sagittal vertical axis (p < 0.05) and increased the lumbar lordosis and pelvic tilt (p < 0.05). Peak hip flexion angle and extension moment during loading response (LR) significantly increased (p < 0.05), and peak hip extension angle and flexion moment during PS statistically decreased (p < 0.05). There was no difference in spatiotemporal data between the two conditions. Our findings suggest that TORF may modify the dynamic sagittal global alignment and lower limb kinematic and kinetics in postoperative LSS patients during level walking.