Efficacy of surgical treatment on polypharmacy of elderly patients with lumbar spinal canal stenosis: retrospective exploratory research.

BACKGROUND: Polypharmacy is a growing public health problem occurring in all healthcare settings worldwide. Elderly patients with lumbar spinal canal stenosis (LSS) who manifest low back and neuropathic pain and have a high frequency of comorbidity are predicted to take many drugs. However, no studies have reported polypharmacy in elderly patients with LSS. Thus, we aimed to review the polypharmacy among elderly LSS patients with elective surgeries and examine how the surgical treatment reduces the polypharmacy. METHODS: We retrospectively enrolled all the patients aged ≥ 65 years who underwent spinal surgery for LSS between April 2020 and March 2021. The prescribed drugs of participants were directly checked by pharmacists in the outpatient department preoperatively and 6-month and 1-year postoperatively. The baseline characteristics were collected beside the patient-based outcomes including Roland-Morris Disability Questionnaire, Zurich Claudication Questionnaire, and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ). The cutoff number of drugs for polypharmacy was defined as 6. The prescription drugs were divided into 9 categories: drugs for neuropsychiatric, cardiovascular, respiratory, digestive, endocrine metabolic, and urinary renal diseases; blood products; pain relief medication; and others. RESULTS: A total of 102 cases were finally analyzed, with a follow-up rate of 78.0%. Of the participants, the preoperative polypharmacy prevalence was 66.7%. The number of drugs 6-month and 1-year postoperatively was significantly less than the preoperative one. The proportions of polypharmacy at 6 months and 1 year after surgery significantly decreased to 57.8% and 55.9%, respectively. When the prescribed drugs were divided into 9 categories, the number of drugs for pain relief and digestive diseases was significantly reduced after surgery. The multi-variable analysis revealed that a higher score in the psychological disorder of JOABPEQ was associated with 3 or more drugs decreased 1-year postoperatively (OR, 2.5; 95% CI: 1.0-6.1). CONCLUSION: Polypharmacy prevalence was high among elderly LSS patients indicated for lumbar spinal surgery. Additionally, our data showed that lumbar spinal surgery was effective in reducing polypharmacy among elderly LSS patients. Finally, the multi-variable analysis indicated that better psychological condition was associated with the reduction of prescribed drugs after lumbar spinal surgery.

Impact of surgical treatment on lipid metabolism in patients with lumbar spinal disorders: Prospective observational study.

PURPOSE: It is still unclear how lumbar spinal surgery affects the lipid metabolism of patients with lumbar spinal disorders (LSDs) such as lumbar spinal canal stenosis and lumbar disk herniation. The present study aimed to assess the impact of lumbar spinal surgery on lipid metabolism in patients with LSDs and clarify the factors associated with changes in visceral fat (VF) accumulation before and after lumbar spinal surgery. METHODS: Consecutive patients with lumbar spinal surgery for LSDs were prospectively included. Abdominal computed tomography images and blood examination of the participants were evaluated before surgery and at 6 months and 1 year after surgery. The cross-sectional VF area (VFA) was measured at the level of the navel using computed tomography images. Blood examination items included triglycerides and high-density lipoprotein (HDL). RESULTS: The study enrolled a total of 138 patients. Female patients with LSDs had significantly increased VFA and serum triglyceride levels after lumbar spinal surgery. On multivariable analysis, the group with > 100 cm2 of preoperative VFA and a postoperative decrease in VFA had a significantly worse preoperative walking ability based on the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (relative risk 2.1; 95% confidence intervals 1.1-4.1). CONCLUSIONS: The present study demonstrated that patients with LSDs did not necessarily improve their lipid metabolism after lumbar spinal surgery. Instead, female patients with LSDs had significantly deteriorated lipid metabolism after lumbar spinal surgery. Finally, a worse preoperative walking ability was associated with the improvement in excess VF accumulation after lumbar spinal surgery.

Impact of oxidized LDL/LOX-1 system on ligamentum flavum hypertrophy.

BACKGROUND: Patients with lumbar spinal canal stenosis (LSS) often have peripheral arterial disease and aortic disease based on atherosclerosis. Oxidized LDL, which is clinically involved in the development of atherosclerosis, may also influence LF hypertrophy, but the function of the oxidized low-density lipoprotein (LDL)/lectin-type oxidized LDL receptor 1 (LOX-1) system in LF hypertrophy is unknown. We aimed to elucidate the potential involvement of oxidized LDL/LOX-1 system in ligamentum flavum (LF) hypertrophy. METHODS: A total of 43 samples were collected from LF tissues of the patients who underwent posterior lumbar spinal surgery. Immunohistochemistry for LOX-1 was performed using human LF samples. We treated the cells in vitro with inflammatory cytokines TNF-α and IL-1ß, oxidized LDL, and simvastatin. The expressions of LOX-1 and LF hypertrophy markers including type I collagen, Type III collagen, and COX-2 were assessed by real-time RT-PCR and immunocytochemistry. Phosphorylation of MAPKs and NF-κb was evaluated by Western blot after treatment with TNF-α, IL-1ß, oxidized LDL, and simvastatin. RESULTS: A significant weak correlation was observed between the number of positive cells of LOX-1 and cross-sectional area of LF on preoperative axial magnetic resonance imaging. In functional analysis, simvastatin treatment neutralized the oxidized LDL-mediated induction of mRNA expressions of LF hypertrophy markers. Western blot analysis showed that oxidized LDL as well as TNF-α and IL-1ß activated the signaling of MAPKs and NF-κb in LF cells, and that simvastatin treatment reduced the phosphorylation of all signaling. The TNF-α and IL-1ß treatments increased both mRNA and protein expression of LOX-1 in LF cells. CONCLUSION: We found a link between the oxidized LDL/LOX-1 system and LF hypertrophy. In addition, our in vitro analysis indicate that oxidized LDL may affect LF hypertrophy through signaling of MAPKs. Our results suggest that the oxidized LDL/LOX-1 system may be a potential therapeutic target for LSS.

Autologous Platelet-Rich Plasma Administration on the Intervertebral Disc in Low Back Pain Patients with Modic Type 1 Change: Report of Two Cases.

Background and Objectives: Modic type 1 is known to be associated with lower back pain (LBP), but at present, a treatment has not been fully established. Meanwhile, platelet-rich plasma (PRP) has been used for tissue regeneration and repair in the clinical setting. There is no clinical PRP injection trial for the intervertebral disc of LBP patients with Modic type 1. Thus, this study aimed to verify PRP injection safety and efficacy in LBP patients with Modic type 1. As a preliminary experiment, two LBP cases with Modic type 1 are presented. Materials and Methods: PRP was administered intradiscally to two LBP patients with Modic type 1. PRP was obtained from the patients' anticoagulated blood. Primary endpoints were physical condition, laboratory data, and X-ray for safety evaluation. Secondary endpoints were pain scores using the visual analog scale (VAS), the Oswestry Disability Index (ODI), and the Roland-Morris Disability Questionnaire (RDQ) to evaluate PRP efficacy. The observation period was 24 weeks after the PRP injection. In addition, changes in Modic type 1 using MRI were evaluated. Results: This study assessed two LBP patients with Modic type 1. There were no adverse events in physical condition, laboratory data, or lumbar X-rays after injection. Follow-up MRI showed a decrease of high signal intensity on T2WI compared to before PRP administration. The pain scores tended to improve after the injection. Conclusions: PRP injection into the intervertebral disc of LBP patients with Modic type 1 might be safe and effective. This analysis will be continued as a prospective study to establish the efficacy.

Elucidation of the Mechanism of Occasional Anterior Longitudinal Ligament Rupture with Posterior Correction Procedure for Adult Spinal Deformity Using LLIF-Finite Element Analysis of the Impact of the Lordotic Angle of Intervertebral LLIF Cage.

Background and Objectives: There are several advantages of using lateral lumbar interbody fusion (LLIF) for correction surgeries for adult spinal deformity (ASD); however, we currently have unresolved new issues, including occasional anterior longitudinal ligament (ALL) rupture during the posterior correction procedure. When LLIF was initially introduced, only less lordotic cages were available and ALL rupture was more frequently experienced compared with later periods when more lordotic cages were available. We performed finite element analysis (FEA) regarding the mechanism of ALL rupture during a posterior correction procedure. Methods: A spring (which mimics ALL) was introduced at the location of ALL in the FEA and an LLIF cage with two different lordotic angles, 6 and 12 degrees (6DC/12DC), was employed. To assess the extent of burden on the ALL, the extension length of the spring during the correction procedure was measured and the location of the rotation center was examined. Results: We observed a significantly higher degree of length extension of the spring during the correction procedure in the FEA model with 6DC compared with that of 12DC. We also observed that the location of the rotation center was shifted posteriorly in the FEA model with 6DC compared with that of 12DC. Conclusions: It is considered that the posterior and rostral edge of the less lordotic angle cage became a hinge, and the longer lever arm increased the burden on ALL as the principle of leverage. It is important to use an LLIF cage with a sufficient lordotic angle, that is compatible with the degree of posterior osteotomy in ASD correction.

Preoperative prevalence of deep vein thrombosis in patients scheduled to have surgery for degenerative musculoskeletal disorders.

BACKGROUND: Although the incidence of symptomatic pulmonary thromboembolism after elective surgery for degenerative musculoskeletal disorders is comparatively low, it is extremely detrimental to both patients and health-care providers. Therefore, its prevention is mandatory. We aimed to perform a cross-sectional analysis of deep venous thrombosis (DVT) before elective surgery for degenerative musculoskeletal disorders, including total knee arthroplasty (TKA), total hip arthroplasty (THA), and spinal surgery, and identify the factors associated with the incidence of preoperative DVT. METHODS: The clinical data of patients aged ≥ 30 years who underwent TKA or THA, and spine surgery for lumbar or cervical degenerative disorders at our institution were retrospectively collected. D-dimer levels were measured preoperatively in all the patients scheduled for surgery. For the patients with D-dimer levels ≥ 1 µg/mL or who were determined by their physicians to be at high risk of DVT, the lower extremity vein was preoperatively examined for DVT on ultrasonography. RESULTS: Overall, we retrospectively evaluated 1236 consecutive patients, including 701 men and 535 women. Of the patients, 431 and 805 had D-dimer levels ≥ 1 and < 1 µg/mL, respectively. Of 683 patients who underwent lower extremity ultrasonography, 92 had proximal (n = 7) and distal types (n = 85) of DVT. The preoperative prevalence of DVT was 7.4 %. No patient had the incidence of postoperative symptomatic venous thromboembolism. A multivariate analysis revealed that age ≥ 80 years (odds ratio [OR], 95 % confidence interval [CI]: 2.8, 1.1-7.3), knee surgery (2.1, 1.1-4.0), American Society of Anesthesiologists (ASA) grade 2 (2.8, 1.2-6.8), ASA grades 3 or 4 (3.1, 1.0-9.4), and malignancy (1.9, 1.1-3.2) were significantly associated with DVT incidence. CONCLUSIONS: This is the first study to conduct a cross-sectional analysis of preoperative DVT data of patients scheduled for elective surgery for degenerative musculoskeletal disorders. Although whether screening for preoperative DVT is needed to prevent postoperative symptomatic pulmonary thromboembolism remains to be clarified, our data suggested that DVT should be noted before surgery in the patients with advanced age, knee surgery, high ASA physical status, and malignancy.

Collagen profiling of ligamentum flavum in patients with lumbar spinal canal stenosis.

BACKGROUND: Although several causes of ligamentum flavum (LF) hypertrophy have been identified, the pathomechanisms underlying LF hypertrophy are not fully understood. Because collagen fibers are essential for the maintenance of LF tissues, characterization of the collagen composition of hypertrophied LF may help to elucidate the pathology of lumbar spinal canal stenosis (LCS). This study aimed to determine the association between the collagen composition and LF hypertrophy. METHODS: LF tissues were collected from 23 patients who underwent spinal decompression surgery for lumbar disorders. The cross-sectional area of LF was measured using the axial images of lumbar MRI. The expression of each collagen in human surgical samples was evaluated by real-time RT-PCR and immunohistochemical analysis. To investigate the impact of inflammatory cytokines on the expression of each collagen, we treated primary human LF cells with TNF-α or IL-1ß. RESULTS: Real-time RT-PCR analysis and immunohistochemistry showed that of the 28 types of collagen, collagen type I, III, V, VI, VIII were highly expressed regardless of LF hypertrophy. In addition, we found the moderate correlation between the cross-sectional area of LF and the mRNA expression level of collagen type I, III, and VI. In vitro analysis showed that the mRNA expression of collagen type I, III, V, VI, and VIII was up-regulated by treatment with TNF-α and with IL-1ß. CONCLUSION: Our results suggested that collagen type I, III, V, VI, and VIII were the main components of the LF extracellular matrix and that collagen type I, III, and VI may serve as useful markers of LF hypertrophy. These findings may contribute to the future development of diagnostic and treatment modalities for LF hypertrophy and even LCS.

Risk Factors for Postoperative Distal Adding-on in Lenke Type 1B and 1C and its Influence on Residual Lumbar Curve.

BACKGROUND: Distal adding-on (DA) in adolescent idiopathic scoliosis is a radiographic complication that can negatively affect clinical results. However, the risk factors for DA and the influences of DA on the residual lumbar curves have not been fully elucidated in Lenke type 1B and 1C curves. The objective of this study was to investigate risk factors for postoperative DA in Lenke type 1B and 1C curves, and the influence of DA on residual lumbar curves. METHODS: We retrospectively evaluated 46 adolescent idiopathic scoliosis patients with Lenke type 1B or 1C curves who underwent posterior correction and fusion surgery with selective thoracic fusion. Patients were grouped according to the presence or absence of DA on radiographs at the 2-year follow-up. We compared coronal radiographic parameters between the 2 groups, including the Cobb angle, L4 tilt angle, apical translation, and relative positions of the end vertebra (EV), stable vertebra (SV), neutral vertebra (NV), and last touching vertebra (LTV) to the lower instrumented vertebra (LIV). RESULTS: DA was present in 11 patients (24%) at the 2-year follow-up, and the mean LIV-EV, LIV-NV, LIV-SV, and LIV-LTV relative positions were significantly smaller in the DA than in the non-DA group. Preoperative radiographic parameters were similar between the 2 groups, including the mean L4 tilt angle (non-DA, -8±4 degrees; DA, -7±4 degrees). At the 2-year follow-up, the mean apical translation of the lumbar curve was smaller in the DA group (non-DA, -16±8 mm; DA, -7±11 mm) and the mean L4 tilt angle was significantly more horizontalized (non-DA, -8±4 degrees; DA, -1±5 degrees). Multivariate analysis showed that the number of levels between the LIV and LTV (LIV-LTV) was significantly associated with DA. CONCLUSIONS: A LIV at or cranial to the LTV was a significant risk factor for postoperative DA in Lenke type 1B and 1C curves. Spontaneous correction of the residual lumbar curve was superior in patients with DA. LEVEL OF EVIDENCE: Level III.

Spinal fractures in patients with diffuse idiopathic skeletal hyperostosis: Clinical characteristics by fracture level.

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) makes the spine prone to unstable fractures with neurological deterioration. This study was conducted to assess clinical and radiographic features of spinal fractures in DISH by the level of spinal injury, and to evaluate the optimal treatment for each level. METHODS: A multicenter retrospective study over a 5-year period, including 46 patients (35 males; 11 females) with a mean age of 77.2 ± 9.7 years at the time of injury. By fracture level, there were 7 cervical (15.2%), 25 thoracic (54.3%), and 14 lumbar (30.4%) fractures. We recorded the cause of injury, whether diagnosis was delayed, and neurological status by Frankel grade. Ossification and fracture patterns were assessed by CT-multi-planar reconstruction (MPR). RESULTS: Neurological status immediately after the cervical-spine injury was C (28.6%) or E (71.4%); after thoracic injury, C (12.0%) or E (88.0%); and after lumbar injury, D (21.4%) or E (78.6%). Inability to walk at admission was more frequent in patients with a spinal-cord injury above the lumbar level (P = .033). Vertebral-body fractures were observed in 14.3% of the cervical injuries, 80.0% of the thoracic injuries, and 50.0% of the lumbar injuries (P = .004). Most patients with a cervical fracture had a disc-level fracture (85.7%). Posterior-column ankylosis was observed in 14.3% of the cervical-fracture group, 72.0% of the thoracic-fracture group, and 78.6% of the lumbar-fracture group (P = .008). CONCLUSION: Ossification and fracture patterns in patients with DISH varied distinctly by the level of spinal injury. Intervertebral-disc fractures were frequently observed in the cervical spine. Delayed diagnosis, vertebral-body fracture, and posterior-column ankylosis were observed in the thoracolumbar spine. This study recommends 3 above and 3 below fusion, to avoid instrumentation failure in the fixation of spinal fracture in patients with DISH.

Exploration for reliable radiographic assessment method for hinge-like hypermobility at atlanto-occipital joint.

PURPOSE: Hinge-like hyper-mobility is occasionally observed at the atlanto-occipital (O-C1) joint. However, it has not been clear if this kind of hinge-like hyper-mobility at the O-C1 joint should be regarded as "pathologic", or referred to as "instability". To solve this issue, we aimed to establish a reliable radiographic assessment method for this specific type of O-C1 instability and figure out the "standard value" for the range of motion (ROM) of the O-C1 joint. METHODS: To figure out the standard range of the O-C1 angle, we acquired magnetic resonance imaging (MRI) sagittal views of the cervical spine for 157 healthy volunteers [average: 37.4 year-old (yo)] without spine diseases, at neutral, maximum flexion and maximum extension positions. RESULTS: The average value (AVE) for ROM of O-C1 angle was 9.91°. The standard value for ROM of O-C1 angle was calculated as 0°-21°. There was no statistically significant gender difference. We also found that the older population (≧ 40 yo) significantly had a larger ROM of O-C1 angle (AVE: 11.72°) compared to the younger population (< 40 yo) (AVE: 8.99°). CONCLUSIONS: We consider that hinge-like instability at O-C1 joint, which cannot be assessed by measuring Powers ratio, can be assessed by measuring the range of O-C1 angles using dynamic-MRI. Evaluation of O-C1 instability is important especially when we perform surgical treatment for diseases with upper cervical instability (such as retro-odontoid pseudotumor). We consider that the current study provides important information in such a case.

Clinical outcomes of late decompression surgery following cervical spinal cord injury with pre-existing cord compression.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The purpose of the current study was to examine the effectiveness of late decompression surgery for traumatic cervical spinal cord injury (CSCI) with pre-existing cord compression. SETTING: Murayama Medical Center, National Hospital Organization, Tokyo, Japan. METHODS: In total 78 patients with traumatic CSCI without bone injury hospitalized in 2012-2015 in our institute for rehabilitation after initial emergency care were divided into four groups according to the compression rate (CR) of the injured level and whether or not decompression surgery was performed. Neurological status was evaluated by American Spinal Injury Association impairment scale (AIS), Barthel index, and Spinal Cord Independence Measure (SCIM). RESULTS: In the severe compression group (CR ≥ 40%), >2 grade improvement in the AIS was observed in 30% of patients with surgical treatment, although it was not observed in any patient without surgery. The SCIM improvement rate at discharge was 60% in the surgical treatment group and 20% in the non-surgical treatment group. In the minor compression group (CR < 40%), >2 grade improvement in the AIS was observed in 18% of patients with surgical treatment and in 11% without surgery. The SCIM improvement rate at discharge was 52% in the surgical treatment group and 43% in the non-surgical treatment group. CONCLUSIONS: These results indicate that surgical treatment has an advantage for patients following traumatic CSCI with severe cord compression. In contrast, surgical efficacy is not proved for CSCI patients without severe cord compression.

Application of q-Space Diffusion MRI for the Visualization of White Matter.

White matter abnormalities in the CNS have been reported recently in various neurological and psychiatric disorders. Quantitation of non-Gaussianity for water diffusion by q-space diffusional MRI (QSI) renders biological diffusion barriers such as myelin sheaths; however, the time-consuming nature of this method hinders its clinical application. In the current study, we aimed to refine QSI protocols to enable their clinical application and to visualize myelin signals in a clinical setting. For this purpose, animal studies were first performed to optimize the acquisition protocol of a non-Gaussian QSI metric. The heat map of standardized kurtosis values derived from optimal QSI (myelin map) was then created. Histological validation of the myelin map was performed in myelin-deficient mice and in a nonhuman primate by monitoring its variation during demyelination and remyelination after chemical spinal cord injury. The results demonstrated that it was sensitive enough to depict dysmyelination, demyelination, and remyelination in animal models. Finally, its utility in clinical practice was assessed by a pilot clinical study in a selected group of patients with multiple sclerosis (MS). The human myelin map could be obtained within 10 min with a 3 T MR scanner. Use of the myelin map was practical for visualizing white matter and it sensitively detected reappearance of myelin signals after demyelination, possibly reflecting remyelination in MS patients. Our results together suggest that the myelin map, a kurtosis-related heat map obtainable with time-saving QSI, may be a novel and clinically useful means of visualizing myelin in the human CNS. SIGNIFICANCE STATEMENT: Myelin abnormalities in the CNS have been gaining increasing attention in various neurological and psychiatric diseases. However, appropriate methods with which to monitor CNS myelin in daily clinical practice have been lacking. In the current study, we introduced a novel MRI modality that produces the "myelin map." The myelin map accurately depicted myelin status in mice and nonhuman primates and in a pilot clinical study of multiple sclerosis patients, suggesting that it is useful in detecting possibly remyelinated lesions. A myelin map of the human brain could be obtained in <10 min using a 3 T scanner and it therefore promises to be a powerful tool for researchers and clinicians examining myelin-related diseases.

CT-based morphological analysis of spinal fractures in patients with diffuse idiopathic skeletal hyperostosis.

PURPOSE: To clarify correlations between spinal fracture and delayed paralysis in patients with diffuse idiopathic skeletal hyperostosis (DISH) using computed tomography (CT) with multiplanar reformatting (CT-MPR). DISH increases susceptibility to unstable spinal fractures, leading to neurological deterioration. The pathomechanism of the neurological injury is unclear. METHODS: This multicenter retrospective study included 42 DISH patients (32 male; 10 female) treated for 45 spinal fractures during a 5-year period. The mean age at the time of injury was 77.1 ± 10.1 years. The cause of injury, delay in diagnosis, fracture location, and neurological status were recorded, and anterior- and posterior-column fractures, a fracture displacement over 3 mm, and posterior-column ankylosis were assessed using CT-MPR. RESULTS: Most fractures (73.8%) resulted from trivial trauma, such as falling from a standing or sitting position. Diagnosis was delayed in 47.6% of the patients, primarily due to delays in seeking medical attention (65.0%). Although 78.6% of the patients were neurologically intact at the time of injury, 54.8% developed paralysis, defined by a change in one or more Frankel-score levels during short-term follow-up. Of the fractures, 39.1% were in the vertebral body, and 60.9% were at the disc level. Fractures with posterior-column ankylosis were significantly associated with delayed paralysis. CONCLUSIONS: CT-MPR was useful for evaluating spinal fractures and determining treatment in patients with DISH. Fractures associated with posterior-column ankylosis resulted in unstable three-column injuries that led to delayed neurological deterioration. Early surgical stabilization of such fractures is recommended to avoid delayed paralysis.

Presence of Modic type 1 change increases risk of postoperative pyogenic discitis following decompression surgery for lumbar canal stenosis.

STUDY DESIGN: Multicenter retrospective study. BACKGROUND: Postoperative surgical site infection is one of the most serious complications following spine surgery. Previous studies do not appear to have investigated pyogenic discitis following lumbar laminectomy without discectomy. This study aimed to identify risk factors for postoperative pyogenic discitis following lumbar decompression surgery. METHODS: We examined data from 2721 patients undergoing lumbar laminectomy without discectomy in five hospitals from April 2007 to March 2012. Patients who developed postoperative discitis following laminectomy (Group D) and a 4:1 matched cohort (Group C) were included. Fisher's exact test was used to determine risk factors, with values of p < 0.05 considered statistically significant. RESULTS: The cumulative incidence of postoperative discitis was 0.29% (8/2721 patients). All patients in Group D were male, with a mean age of 71.6 ± 7.2 years. Postoperative discitis was at L1/2 in 1 patient, at L3/4 in 3 patients, and at L4/5 in 4 patients. Except for 1 patient with discitis at L1/2, every patient developed discitis at the level of decompression. The associated pathogens were methicillin-resistant Staphylococcus aureus (n = 3, 37.5%), methicillin-susceptible Staphylococcus epidermidis (n = 1, 12.5%), methicillin-sensitive S. aureus (n = 1, 12.5%), and unknown (n = 3, 37.5%). In the analysis of risk factors for postoperative discitis, Group D showed a significantly lower ratio of patients who underwent surgery in the winter and a significantly higher ratio of patients who had Modic type 1 in the lumbar vertebrae compared to Group C. CONCLUSIONS: Although further prospective studies, in which other preoperative modalities are used for the evaluation, is needed, our data suggest the presence of Modic type 1 as a risk factor for discitis following laminectomy. Latent pyogenic discitis should be carefully ruled out in patients with Modic type 1. If lumbar laminectomy is performed for such patients, more careful observation is necessary to prevent the development of postoperative discitis.

Walking sagittal balance correction by pedicle subtraction osteotomy in adults with fixed sagittal imbalance.

PURPOSE: Pedicle subtraction osteotomy (PSO) is widely used to treat severe fixed sagittal imbalance. However, the effect of PSO on balance has not been fully documented. The aim of this study was to assess dynamic walking balance after PSO to treat fixed sagittal imbalance. METHODS: Gait and balance were assessed in 15 consecutive adult female patients who had been treated by PSO for a fixed sagittal imbalance and compare patients' preop and postop dynamic walking balance with that of 15 age- and gender-matched healthy volunteers (HV). Each patient's chart, X-rays, pre and postop SRS22 outcome scores, and ODI were reviewed. Means were compared by Mann-Whitney U test and Chi-square test. RESULTS: The mean age was 66.3 years (51-74 years). The mean follow-up was 2.7 years (2-3.5 years). The C7PL and GL, measured on the force platform, were both improved from 24.2 ± 7.3 cm and 27.6 ± 9.4 to 5.4 ± 2.6 cm and 7.2 ± 3.4 cm, respectively. The baseline hip ROM was significantly smaller in patients compared to HV, whereas no significant difference was observed in the knee or ankle ROM. The pelvic tilt (preop -0.4° ± 1.4°, postop 8.9° ± 1.0°), and maximum hip-extension angle (preop -1.2° ± 14.2°, postop -11.2° ± 7.2°) were also improved after surgery. Cadence (116 s/min), stance-swing ratio (stance 63.2 % vs. swing 36.8 %), and stride (98.0 cm) were all increased after surgery. On the other hand, gait velocity was significantly slower in the PSO group at both pre and postop than in HV (PSO 53.3 m/min at preop and 58.8 m/min at postop vs. HV 71.1 m/min, p = 0.04). CONCLUSIONS: Despite a mild residual spinal-pelvic malalignment, PSO restored sagittal alignment and balance satisfactorily and has improved the gait pattern.

Association between frailty and locomotive syndrome in elderly patients with lumbar spinal stenosis: A retrospective longitudinal analysis.

AIMS: With the aging society worldwide, lumbar spinal stenosis (LSS) has become common, and its incidence has been increasing worldwide. Frailty and locomotive syndrome significantly overlap as disorders in older people. The current study aimed to validate the association between frailty and locomotive syndrome in patients with LSS. In particular, the involvement of frailty in locomotive syndrome following surgery was examined. METHODS: We retrospectively reviewed the time-course data of consecutive patients aged ≥65 years who underwent lumbar spinal surgery for LSS. The locomotive syndrome stages were determined using the 25-Question Geriatric Locomotive Function Scale: stage 0, score ≤6; stage 1, score ≥7; stage 2, score ≥16; and Stage 3, score ≥24. Robust, pre-frailty, and frailty were defined as a modified frailty index-11 score of 0, <0.21, and >0.21, respectively. RESULTS: This study included 234 patients. All patients except one were diagnosed with locomotive syndrome preoperatively. Approximately 24.8% of participants were diagnosed with frailty. LSS surgery improved locomotive syndrome regardless of frailty severity. Meanwhile, multivariable analysis indicated that frailty could significantly inhibit improvement in locomotive syndrome after surgery in old patients with LSS (estimated relative risk: 0.6; 95% confidence interval: 0.4-0.9). CONCLUSIONS: This study first assessed the association between locomotive syndrome and frailty in patients with LSS. Locomotive syndrome could be managed effectively with surgery regardless of frailty severity in old patients with LSS. However, our findings emphasize the need to screen for frailty preoperatively in this patient group. Geriatr Gerontol Int 2024; 24: 116-122.

Spinal Epidural Tuberculoma with Adjacent Vertebral Fracture: A Case Report.

CASE: An 85-year-old woman was transported to our institution due to difficulty in walking. Preoperative imaging showed spinal cord lesions indicative of spinal cord tumor at the T7-8 level, accompanied by T8 vertebral fracture. Intraoperatively, the spinal lesion was suspected to be an epidural abscess; therefore, the capsule was resected, and the abscess was drained. We added pedicle screw fixation at the T6-10 level. Postoperatively, the spinal cord lesion was definitively diagnosed as spinal epidural tuberculoma. CONCLUSION: Spinal epidural tuberculomas should be considered in the treatment of spinal cord lesions causing paralysis attributed to spinal cord compression.

Assessment of Surgical Outcomes in Patients with Degenerative Cervical Myelopathy Using the 25-Question Geriatric Locomotive Function Scale: A Longitudinal Observational Study.

Introduction: Locomotive syndrome caused by degenerative musculoskeletal diseases is reported to improve with surgical treatment. However, it is unclear whether surgical treatment is effective for the locomotive syndrome developing in patients with degenerative cervical myelopathy (DCM). Thus, this study primarily aimed to longitudinally assess the change in locomotive syndrome stage before and after cervical spinal surgery for patients with DCM using the 25-question geriatric locomotive function scale (GLFS-25). A secondary objective was to identify factors associated with the postoperative improvement in the locomotive syndrome stage. Methods: We retrospectively reviewed clinical data of patients undergoing cervical spine surgery at our institution from April 2020 to May 2022 who had answered the Japanese Orthopaedic Association Cervical Myelopathy Assessment Questionnaire, visual analog scale, and GLFS-25 preoperatively and at 6 months and 1 year postoperatively. We collected demographic data, medical history, preoperative radiographic parameters, presence or absence of posterior longitudinal ligament ossification, and surgical data. Results: We enrolled 115 patients (78 men and 37 women) in the present study. Preoperatively, using the GLFS-25, 73.9% of patients had stage 3, 10.4% had stage 2, 9.6% had stage 1, 6.1% had no locomotive syndrome. The stage distribution of locomotive syndrome improved significantly at 6-months and 1-year postoperatively. The multivariable Poisson regression analysis revealed that better preoperative lower extremity function (relative risk: 3.0; 95% confidence interval: 1.01-8.8) was significantly associated with postoperative improvement in the locomotive syndrome stage. Conclusions: This is the first study to longitudinally assess the locomotive syndrome stage in patients with DCM using GLFS-25. Our results indicated that patients with DCM experienced significant improvement in the locomotive syndrome stage following cervical spine surgery. Particularly, the preoperative lower extremity function was significant in postoperative improvement in the locomotive syndrome stage.

Predictors of Patient Dissatisfaction after Lumbar Spinal Canal Stenosis Surgery: A Multicenter Retrospective Study.

Introduction: Recently, patient satisfaction has gained prominence as a crucial measure for ensuring patient-centered care. Furthermore, patient satisfaction after lumbar spinal canal stenosis (LCS) surgery is an important metric for physician's decision of surgical indication and informed consent to patient. This study aimed to elucidate how patient satisfaction changed after LCS surgery to identify factors that predict patient dissatisfaction. Methods: We retrospectively reviewed time-course data of patients aged ≥40 years who underwent LCS surgery at multiple hospitals. The participants completed the Zurich Claudication Questionnaire (ZCQ) and the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) before surgery and then 6 months and 1 year postsurgery. Patient satisfaction was categorized according to the postoperative score of the satisfaction domain of the ZCQ: satisfied, score ≤2.0; moderately satisfied, 2.0< score ≤2.5; and dissatisfied, score >2.5. Results: The study enrolled 241 patients. Our data indicated a satisfaction rate of around 70% at 6 months and then again 1 year after LCS surgery. Among those who were dissatisfied 6 months after LCS surgery, 47.6% were more satisfied 1 year postsurgery. Furthermore, 86.2% of those who were satisfied 6 months after LCS surgery remained satisfied at 1 year. Multivariable analysis revealed that age (relative risk, 0.5; 95% confidence interval, 0.2-0.8) and preoperative score of psychological disorders on the JOABPEQ (relative risk, 0.2; 95% confidence interval, 0.03-0.08) were significantly associated with LCS surgery dissatisfaction. In addition, the receiver operating characteristic curve analysis revealed that the cutoff value for the preoperative score of psychological disorder of the JOABPEQ was estimated at 40 for LCS surgery dissatisfaction. Conclusions: Age and psychological disorders were identified as significant predictors of dissatisfaction, with a JOABPEQ cutoff value providing potential clinical applicability.